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THE  DIAGNOSIS  OF  DISEASES 
OF  THE  CORD, 


LOCATION  OF  LESIONS, 


BY 


Dr.  Grasset, 


CLINICAL    PROFESSOR   AT   THE    UNIVERSITY   OF    MONTPELLIER,    ASSOCIATE 

OF    THE   NATIONAL   ACADEMY    OF    MEDICINE, 

LAUREATE    OF   THE   INSTITUTE. 


TRANSLATED    BY 

Jeanne  C.  Solis,  M.D., 

DEMONSTRATOR    OF    NERVOUS    DISEASES   AND    ELECTRO-THERAPEUTICS 
IN   THE    UNIVERSITY    OF    MICHIGAN. 


GEORGE  WAHR, 

PUBLISHER, 

ANN  ARBOR,  MICHIGAN. 


Copyright,  1901, 
By  GEORGE  WAHR. 


THE  DIAGNOSIS 

OF 


DISEASES  OF  THE  CORD, 


INTRODUCTION. 

Given  a  patient  in  whom  a  disease  of  the  cord 
has  been  recognized,  how  can  the  exact  location  of 
the  mediillarv  chans^e  be  determined  cHnicallv? 

What  system  or  systems  of  the  cord  are  exclu- 
sively or  principally  attacked? 

At  what  level  of  the  spinal  axis  is  the  lesion  lo- 
cated ? 

I  wish  to  sum  up  here  the  elements  of  the  answer 
the  present  neuro-pathology  permits  to  this  ques- 
tion, which  is  an  interesting  one  to  practitioners 
generally. 

For  if  this  chapter  of  clinical  geography  of  the 
cord,  founded  by  the  chiefs  of  the  French  neuro- 
pathological  school,  Duchenne,  of  Boulogne,  Vul- 
pian  and  Charcot,  seemed  at  the  beginning  a  chapter 
of  pure  science,  today  it  has  been  so  enlarged,  con- 
firmed and  made  so  exact  that  it  is  now  absolutely 
practical,  accessible  and  useful  to  all. 

In  the  first  place  the  necessary  indications  for 
surgical  intervention  were  found  here.  This  field 
increases  every  day  in  proportion  as  the  operations 
become  less  dangerous  and  their  technique  is  per- 
fected. 

Further,  the  different  conditions  called  classic- 
ally diseases  of  the  cord  are  anatomico-clinical  syn- 
dromes characterized  by  the  fixity  of  their  svmp- 


374568 


4  Introduction. 

toms  and  the  fixity  of  the  location  of  the  correspond- 
ing lesion.  Whence  it  results  that  the  diagnosis  of 
this  location  of  the  lesion  constitutes  the  complete 
diagnosis  of  this  syndrome. 

Thus  to  recognize  progressive  muscular  atrophy 
or  tabes,  it  is  sufficient  to  recognize  that  the  lesion, 
in  the  patient  examined,  is  located  in  the  anterior 
horns  of  the  grey  substance  or  in  the  posterior  bun- 
dles. 

Then^  without  denying  the  importance  of  ana- 
tomical and  nosological  diagnoses  which  when  pos- 
sible should  complete  the  physiological,  it  may  be 
said  that  the  physiological  diagnosis  of  the  location 
of  the  lesion  is  absolutely  of  primary  necessity  for 
all  physicians  today. 

The  natural  division  of  this  little  book  is  into 
two  chapters,  ist.  In  the  first  chapter  we  will  study 
the  semeiology  of  the  systems  of  the  cord,  that  is  to 
say,  the  signs  by  which  is  recognized  the  location 
of  the  medullary  change  in  such  or  such  system  of 
this  organ  (anterior  horns,  posterior  horns,  poster- 
ior columns,  etc).  2nd.  In  the  second  chapter  we 
will  seek  to  make  a  diagnosis  of  the  location  of  the 
lesions. 

The  study  of  the  clinical  anatomy  of  the  cord 
ought  to  be  the  appointed  prelude  and  indispensable 
basis  for  pathology.  For  it  is  useless  to  refer  to  the 
ordinary  anatomical  description.  Anatomical  anatomy 
is  useful  to  the  clinician ;  it  is  the  foundation.  But 
physiological  anatomy  is  still  more  necessary.  A 
symptom  is  a  function  pathologically  deviated.  Then 
it  is  necessary  to  have  a  basis  of  functional  or  physio- 
logical groupings  of  organs  to  make  a  work  useful  in 
practical  medicine. 

This  study  which  requires  too  much  to  be  made 
here,  will  be  the  object  of  a  special  publication. 


I.   THE  DIAGNOSIS  OF  DISEASE  OF  THE 
MEDULLARY  SYSTEM. 

We  will  study  successively  in  this  chapter  the 
eight  following  syndromes : 

1.  The  syndrome  of  the  posterior  columns:  sen- 
sory troubles  and  ataxia ; 

2.  The  syndrome  of  the  antero-lateral  columns : 
pareto-spasmodic  state,  contractures  and  intentional 
tremor. 

3.  The  associated  syndrome  of  the  posterior  and 
lateral  columns  :  ataxo-spasmodx  state ; 

4.  The  syndrome  of  the  anterior  horns :  muscu- 
lar atrophy ; 

5.  The  associated  syndrome  of  the  anterior 
horns  and  the  lateral  columns :  spastic  muscular 
atrophy ; 

6.  The  syndrome  of  the  centro-posterior  grey 
substance :  dissociation  of  sensation,  called  syringo- 
myelic (and  vaso-motor  troubles)  ; 

7.  The  associated  syndrome  of  the  anterior 
horns  and  of  the  centro-posterior  grey  substance 
(syndrome  of  the  whole  grey  substance)  :  muscular 
atrophy,  dissociation  of  sensation,  called  synngo- 
myelic,  and  vaso-motor  troubles  ; 

8.  The  syndrome  of  the  lateral  half  of  the  cord : 
hemiparaplegia  crossed. 

For  each"  syndrome  we  will  study  successively: 
1st.  The  group  of  cases  in  which  the  lesion  is  lim- 
ited to  this  system  (lesions  and  symptoms)  ;  2nd. 
Those  in  which  the  lesion  attacks  this  system  without 
being  exclusively  limited  to  it  (lesions  and  symp- 
toms) ;  3rd.  The  synthesis  of  the  syndrome  (clinical 
description,  pathological  physiology  and  differential 
diagnosis). 

5 


6         .  The  Diagnosis  of 

1.    The  Syndrome  of  the  Posterior  Coluiuus: 
Sensory  Troubles  and  Ataxia. 

A.  There  is  only  one  group  of  cases  in  which  th^ 
lesion  is  systematically  limited  to  the  posterior  col- 
umns -.tabes  or  progressive  locomotor  ataxia. 

Let  us  sum  up  the  lesions  and  symptoms. 

I.  Although  a  gelatinous  degeneration  of  the 
posterior  columns  of  the  cord  was  anatomically 
noted  by  Hutin  in  1827,  it  may  be  said  that  the  path- 
ological anatomy  of  tabes  began  with  Bourdon  and 
Luys  (i860)  a  short  time  after  the  masterly  clinical 
description  of  Duchenne  (1858). 

In  the  first  period  a  primary  systematic  sclerosis 
of  the  posterior  columns  in  their  entirety  was 
claimed ;  in  the  second  period  ( Charcot  and  Pierret, 
1 87 1)  more  was  determined:  The  principal,  initial 
lesson  was  localized  in  the  external  part  of  the  pos- 
terior columns  (posterior  root  zones). 

Finally  in  the  third  period,  the  lesion  of  the  pos- 
terior roots  appeared  most  constant  (Leyden  and 
Vulpian)  :  then  the  starting  point  of  the  lesion  was 
placed  in  the  ganglions  (P.  ]\Iarie,  1892)  and  tabes 
was  made  a  disease  of  the  sensory  protoneurone 
(Brissaud  1895,  deAIassary^  1896). 

In  fact,  the  lesions  of  tabes,  in  the  beginning  is 
localized  in  the  external  bundle  of  Charcot  and  Pi- 
erret; then  in  the  more  advanced  stage  it  includes 
the  zone  of  the  entrance  of  the  posterior  roots  of 
Philippe,  that  is  the  zone  of  Lissauer  and  the  cornu- 
root  zone  of  ]\Iarie.     Finally  in  a  case  of  long  dura- 

^Massary  (de).  Le  tabes  dors,  degener.  du  protoneur. 
centrip.  Th.  Paris,  1896. — Voir  aussi  pour  ce  paragraphe : 
Philippe.  Le  tabes  dorsalis.  Paris,  1897 :  et  Gerest.  Les 
affections  nerveuses  systematiques  et  la  theorie  des  neur- 
ones.    Paris,  1898. 


Diseases  of  the  Cord.  7 

tion  the  column  of  GoU  is  invaded,  especially  in  the 
upper  portion  of  the  cord.  The  principal  and  con- 
stant lesion  is  in  the  exogenous  fibres,  root  fibres,  cyl- 
inder axis  prolongations  of  the  ganglions.  The  en- 
dogenous fibres  often  found  intact  (Marie,  Strum- 
pell),  have  also  been  found  involved  (Philippe)  ; 
the  descending  fibres  at  first  (triangle  of  Gombault 
and  Philippe,  oval  center  of  Flechsig,  postero-inter- 
nal  band,  comma  tract  of  Schultze),  the  ascending 
fibres  latei*  (the  cornucommisural  zone  dying  last  of 
the  posterior  columns).  But  all  these  endogenous 
fibres  will  be  attacked  only  in  the  second  stage  con- 
secutive to  the  lesion  of  the  exogenous  root  fibres. 

In  the  grey  substance  the  lesion  of  the  cells  of 
the  vesicular  column  of  Clarke  is  doubtful  or  incon- 
stant ;  the  alteration  of  the  nerve  fibres  of  this  same 
region  (the  collaterals  given  off  by  the  posterior 
root  fibres)  is  on  the  contrary  very  frequent. 

The  lesion  of  the  posterior  root  is  very  frequent 
but  not  constant.  In  the  ganglions  the  cells  as  a 
rule  are  intact.^ 

Let  us  omit  all  extra-medullary  lesions  (nerves, 
bulb),  which  are  of  no  interest  here. 

Brissaud's  conception  then  that  tabes  is  a  lesion 
of  the  sensory  protoneurone  may  be  admitted.  Only, 
if  we  do  not  wish  to  admit  a  dynamic  or  un- 
recognized lesion  of  the  ganglion  in  many  cases,  it 
is  necessary  to  say  that  the  primary,  essential  loca- 
tion of  the  lesion  in  tabes  is  the  intra-medullary  part 
of  the  sensory  protoneurone,  that  part  of  the  pos- 
terior column  which  we  know  contains  the  cylinder 
axis  prolongations  of  the  spinal  ganglions. 

If  with  Brissaud  we  compare  the  neurone  to  a 
tree,    the    sensory   protoneurone    is    attacked    in    its 

"Voir  sur  ce  point  important :  Gerest.    Loc.  cit.,  p.  235. 


8  The  Diagnosis  of 

branches.  We  shall  see  that  in  spasmodic  tabes  the 
same  way  the  disease  in  the  pyramidal  bundle  is  in 
the  intra-medullary  portion  of  the  cylinder  axis  pro- 
longations of  the  cortical  motor  protoneurone.  Both 
ataxic  tabes  and  the  spasmodic  are  diseases  of  the 
intra-medullary  prolongations  of  the  extra-medul- 
lary neurone.  (The  spinal  ganglion  for  posterior 
tabes,  the  cerebral  cortex  for  lateral  tabes). 

Anatomically  this  change  in  the  posterior  root 
fibres  in  tabes  involves  the  myeline  especially,  and 
degenerations  at  first  descending  and  then  ascend- 
ing in  the  endogenous  fibres  follow  this  primary 
process. 

The  topography  alone  of  the  lesions  is  what  in- 
terests us  here,  as  we  shall  write  a  chapter  on  medul- 
lary geography  alone. 

2.  We  ought  now  to  put  together  from  this  loca- 
tion of  the  lesion  the  important  and  essential  symp- 
toms of  tabes,  at  least  those  which  are  clearly  of 
medullary  origin.  They  may  be  said  to  have  been 
nearly  all  described  by  Duchenne^  in  his  historical 
memoir  of  1858  and  by  Charcot*  in  his  ''Lecons  de 
la  Salpetriere." 

They  may  be  grouped  under  the  following 
heads :  lightning-like  pains,  visceral  crises  ( gastric, 
etc.),  girdle  sensation,  anaesthesias  and  paraesthe- 
sias,  plantar  anaesthesia  in  patches,  tingling  in  the 
forearm,  retarded  and  false  localization,  abnormal 
painful  persistence  of  the  sensations  excited,  dissocia- 
tion (persistence  of  thermal  sensibility),  diminution 
or  abolition  of  the  muscular  sense,  abolition  of  the 
patellar  tendon  reflex    (Westphal),  of  the  Achilles 

"DucHENNE.  De  I'ataxie  locom.  progr.  Arch,  gen  de 
med.  1858-1859. 

^Charcot.  CEuv.  compl.,  t  I,  Leg.  II,  III  et  IV;  t.  II. 
Leg.  II  et  IV. 


Diseases  of  the  Coi'd.  9 

tendon  reflex  (Babinski),^ diminution  or  abolition  of 
muscular  tonicity,  hypotonicity  (Frenkel)/^  involun- 
tary movements  in  repose  (ataxia  of  tonicity),'  pare- 
sis or  paralysis  of  the  sphincters  (vesical  troubles), 
motor  incoordination,  influence  of  closing  the  eyes  on 
the  upright  position  and  on  the  gait  (Romberg), 
trophic  troubles,  arthropathies,  osteopathies,  ecchy- 
moses,  perforating  ulcer. 

B.  In  a  series  of  diseases  we  find  the  posterior 
columns  involved,  the  lesion  not  being  exclusively 
limited  to  this  system.  We  will  rapidly  review 
them:  General  paralysis,  disseminated  sclerosis, 
Friedreich's  disease,  syringo-myelia,  spinal  menin- 
gitis. 

I.  The  relation  between  tabes  and  general  paral- 
ysis has  been  much  discussed  since  Baillarger,^  that 
is  to  say  the  question  of  posterior  spinal  lesions  in 
general  paralysis.^ 

First  it  must  be  admitted  that  tabes  and  general 
paralysis  are  two  distinct  diseases  in  order  that  the 
discussion  take  place. 

In  one  group  of  cases,  tabes  and  general  paraly- 
sis are  frequently,  according  to  some  (Ballet  and 
Renaud)  rarely,  according  to  others  (Joft'roy  and 
Rabaud)  superimposed  in  the  same  subject.  These 
cases  from  this  point  of  view  belong  to  our  preced- 

^Babinski.    Soc.  med.  des.  hop.,  21  oct.  1898. 

®Frenkel.  Ueb.  Muskel-Schlaffheit  (Hypotonic)  b.  d, 
tabes  dors.  Neurol.  Centralhl.  1896,  t.  XV,  p.  355. 

'Voir  nos  leg.  sur  les  mouvem.  involont.  au  repos,  chez 
les  tabet.  Ataxic  du  tonus,  in  Leg.  de  Clin.  med.  2^  serie, 
1896,  p.  271. 

^Baillarger.  De  la  paral.  gener.  dans  scs  rapp.  avec  I'at. 
locom.  Ann.  med.  psychol.   1862,  t.  VII. 

"Voir  pour  tout  ce  paragraphc :  Rabaud.  Contr.  a  Tet. 
des  lesions,  spin,  poster,  dans,  la  paral  gener.  Th.  Paris, 
1898. 


lo  The  Diagnosis  of 

ing  paragraph  ''A."     For  tabes  is  always  the  same 
symptomatically  and  anatomically,  whether  associ- 
ated or  not  with  another  disease,  as  general  paraly-^ 
sis. 

Then  there  is  another  group  (which  is  especially 
interesting  here)  in  which  general  paralysis  (a  sin- 
gle disease)  has  symptoms  and  lesions  of  a  posterior 
medullary  location. 

The  lesions  in  this  case  closely  resemble  those  of 
tabes,  in  a  section  of  cord  examined  by  an  expert 
observer.  Tlie}^  differ  only  in  the  discontinuity, 
diffusion  and  irregularity  of  the  sclerosed  zones,  the 
relative  or  absolute  integrity  of  the  posterior  roots, 
and  Lissauer's  zones,  the  frequency  or  constancy  of 
cellular  lesions  of  the  grey  substance.  (Rebaud). 

For  the  symptoms,  we  find  also  from  the  clinical 
tables  such  as  for  a  long  time  have  been  diagnostic 
of  tabes.  But  the  appearance  of  cerebral  symptoms 
disturbs  the  picture.  Thus  the  tendon  reflexes  then 
become  exaggerated  and  the  special  motor  troubles 
of  the  general  paralytic  replace  the  true  ataxia  with 
Romberg's  symptom. 

2.  Disseminated  sclerosis  has  for  a  long  time  been 
considered  as  a  disease  principally  if  not  exclusively 
motor  because  of  Charcot's^*^  masterly  description. 
But  the  patches  of  sclerosis  may  be  located  also  in 
the  posterior  columns ;  and  may  simulate  to  a  certain 
point  that  of  locomotor  ataxia;  Romberg's  sign, 
motor  incoordination,  lightning  pains,  hypsesthe- 
sias,  and  even  urinary  troubles  (Erb  Oppenheim). 

The  same  observation,  adds  Raymond,^^  "was  re- 
ported to  me  by  one  of  our  present  internes  of  a 
patient  who  died  during  the  service  of  M.  Gaucher 

^"Charcot.    CEuv.  compl.,  t.  V,  Leg.  VI,  VII  et  VIII. 
"Raymond.    Leg.,  sur  les  mal.  du  syst.  nerv.  1897,  t.  II, 
P-  550. 


Diseases  of  the  Cord.  1 1 

.at  the  hospital  of  Samt  Antoine.  During  his  Hfe 
this  patient  had  presented,  independently  of  a  gen- 
eral spasmodic  stiffness,  severe  pains  in  the  ex- 
tremities, both  upper  and  lower,  imputable  to 
patches  of  sclerosis  in  the  posterior  columns  and  the 
corresponding  roots." 

3.  According  to  the  latest  works  the  principal 
lesion  in  Friedreich's  disease  (Hereditary  Ataxia)  is 
in  the  posterior  columns,  but  especially  in  the  col- 
umn of  Goll  and  also  in  the  column  of  Gower  and 
the  direct  cerebellar  tracts  and  their  origin  in  the 
grey  substance  (the  cells  of  Clarke's  column). 

Among  the  symptoms  corresponding  to  this  le- 
sion note :  on  one  hand,  an  ataxia  which  is  related 
rather  to  the  cerebellar  ataxia  than  to  that  of  tabes 
in  that  it  is  accompanied  by  staggering  and  is  only 
slightly  modified  by  closure  of  the  eyes  (the  tabeto- 
cerebellar  gait  of  Charcot),  spontaneous  movements 
(ataxia  of  tonus)  and  abolition  of  the  tendon  re- 
flexes, on  the  other  hand  there  is  usually  absence  of 
sensory  affections  (anaesthesias)  and  of  lightning 
pains. 

4.  In  syringo-myelia  the  lesion  does  not  gener- 
ally affect  the  posterior  columns.  But  in  certain 
cases  these  columns  may  participate  in  the  lesions 
and  these  cases  pertain  here. 

Raymond^-  has  collected  quite  a  large  number  of 
observations  on  syringo-myelia  in  which  the  anaes- 
thesia was  complete  instead  of  dissociated.  In  these 
•cases  the  lesion  involves  the  posterior  columns. 

Such  are  the  cases  of  Joffroy  and  Achard,  Ho- 
Tnen,  Oppenheim,  and  Schuppel. 

In  a  word,  Schlesinger,  who  has  made  the  best 

^^Raymond.     Leg.    sur  les   mal.    du   syst.    nerv.    1897,   2© 
serie,  p.  510. 


12  The  Diagnosis  of 

study  of  the  participation  of  the  posterior  columns 
in  syringo-myeha  has  shown  that  in  these  columns 
three  regions  were  especially  invaded  by  the  glioma- 
tosis  /.  e.  1st.  The  part  contiguous  to  the  posteriof 
grey  commissure;  2nd.  The  portions  of  the  column 
of  Goll  adjacent  to  the  posterior  median  fissure; 
3rd.  The  zone  between  the  columns  of  Goll  and 
Burdach. 

5.  Chronic  spinal  meningitis  and  more  especially 
leptomeningitis  (the  inflammation  of  the  pia-materj 
are  associated  with  lesions  of  the  posterior  columns. 
This  is  the  condition  in  the  cases  of  tabes  with  con- 
comitant meningitis  (Vulpian,  Dejerine). 

6.  In  ergotism  Tuczek^"  described  (  Aj  clinically, 
''paraesthesias,  such  as  tinglings,  numbness,  light- 
ning pains,  girdle  pains,  diminution  of  sensation  to 
pain,  lack  of  equilibrium  when  the  eyes  are  closed," 
ataxia  and  finally  abolition  of  the  knee  jerks;  (B) 
anatomically,  lesions  of  Burdach's  columns,  Goll's 
being  intact.  In  a  word,  symptomatically  and  ana- 
tomically tabes. ^^ 

7.  Equally  well  Tuczek  studied  the  medullary 
lesions  of  pellagra  :^'^  the  posterior  columns  are  at- 
tacked in  the  column  of  Goll  with  integrity  of  the 
column  of  Burdach,  the  symptoms  depending  upon 
this  lesion  are  nearly  none:  knee  jerk  is  more  often 
exaggerated  than  abolished,  no  anaesthesia,  no  true 
ataxia  except  at  times  in  the  upper  extremities. 

In  the  same  part  of  the  posterior  cord  medullary 

^^Voir  P.  Marie  in  Traite  de  med.  de  Charcot  Bouchard, 
1894,  t.  VI,  p.  314. 

^■^Rapprocher  notre  note  sur  les  ''Dangers  du  seigle  er- 
gote  dans  I'ataxie  locom.  progress."  Progres  medical,  ij 
mars  1884. 

^^Voir  P.  Marie  in  Traite  de  med.  1894,  t.  VI,  p.  319. 


Diseases  of  the  Cord.  13 

lesions  have  been  described  in  lepra. ^*^  But  these 
lesions  seem  secondary  and  it  is  impossible  to  at- 
tribute to  them  a  special  symptomatologx'  in  the 
midst  of  the  clinical  picture  of  this  disease. 

C.  With  the  aid  of  these  various  proofs  we  can 
now  make  the  synthesis  and  the  pathological  physi- 
ology of  the  syndrome  of  the  posterior  columns. 

The  symptoms  given  may  be  grouped  under  two 
heads  :  Sensory  troubles  and  ataxia. 

The  sensory  troubles  are :  Lightning-like  pains, 
paraesthesias,  anaesthesias^  (especially  of  the  mus- 
cular sense)  and  abolition  of  the  tendon  reflexes. 

A.11  these  symptoms  are  explained  by  a  lesion  of 
the  root  fibres  of  the  posterior  columns  (intra- 
medullary prolongations  of  the  ganglionic  sensory 
protoneurone )  or  of  the  first  neurones  of  the  relays 
(ascending  prolongations  of  the  neurones  of  the 
posterior  horns). 

The.  mechanism  of  ataxia  from  a  lesion  of  the 
posterior  column  has  been  and  still  is  much  dis- 
cussed. 

Walking,  all  movements,  even  the  most  simple 
in  appearance,  and  the  maintaining  of  the  body  in 
whatever  position,  are  really  complex  acts.  Immo- 
bility itself  is  active.  It  is  the  cord  itself  w^hich  pre- 
sides over  the  coordination  of  the  muscular  con- 
tractions and  relaxations  necessary  to  obtain  and 
maintain  each  position.  Tonus  is  a  part  of  this  gen- 
eral function ;  it  is  concerned  in  the  maintenance  of 
immobility  in  one  position  and  one  attitude. 

This  medullary  influence  is  a  reflex  one.  The 
centripetal  excitation  of  this  reflex  comes  from  the 
skin,  the  joints,  and  especially  the  muscles.  This 
excitation  penetrates  the  cord  by  the  posterior  roots 

^^'Voir  Jeanselme  et  Marie.     Sur  les  les.  des  cord,  pos- 
ter, dans  la  moelle  des  leprenx.     Revue  neurol.  1898,  p.  751. 


14  The  Diagnosis  of 

and  the  root  fibres  of  the  posterior  columns.  It  can 
be  comprehended  easily  how  an  alteration  of  these 
columns  seriously  interferes  with  this  reflex; 
whence  we  have  general  hypotonia,  sphincter  trou- 
bles, loss  of  tendon  reflexes,  and  ataxia  (of  movement 
and  of  tonus). 

Some  centripetal  impressions  useful  in  this  me- 
dullary function  of  regulation  come  also  by  the 
senses  and  particularly  by  sight. 

In  the  normal  state  these  sensorial  excitations 
are  secondary  and  accessory  and  can  at  a  given  mo- 
ment fail  without  much  interference  with  equil- 
ibrium and  the  coordination  of  movements.  Wlien, 
on  the  contrary,  in  consequence  of  a  lesion  of  the 
posterior  columns  the  excitations  normally  the  chief 
ones  (muscle)  fail,  the  sensorial  excitations  become 
important ;  the  patients  then  use  their  eyes  as  crutches 
(Althaus),  and  their  sudden  closure  causes  an  in- 
creased disturbance  in  coordination,  Romberg's  sign. 
That  is  not  saying  that  the  ataxic  watches  or  is 
obliged  to  watch  his  feet,  but  he  uses  his  eyes  to 
take  from  around  him  marks  and  fulcrums  to  make 
up  for  the  reflex  automatism  of  his  cord.  He  walks 
with  his  brain  in  place  of  with  his  cord.  And  when 
this  help  fails  he  loses  his  equilibrium  by  a  kind  of 
sudden  vertigo  which  is  Romberg's  sign. 

From  this  it  is  seen  that  contrary  to  the  classical 
opinion  it  is  not  necessary  to  consider  Romberg's 
sign  as  the  consequence  of  the  loss  or  diminution  of 
the  muscular  sense.  I  believe  I  have  demon- 
strated^' that  there  is  no  parallelism  nor  necessary 

^'Du  vert,  des  atax.  (signe  de  Romberg)  in  Leg.  _de  clin. 
med.  1896,  26  serie,  p.  312. — Rapprocher  cette  definition  du 
vertige:  '1a  conscience  du  trouble  de  I'equilibre  du  corps", 
(Frank  K.  Hallock^  Journ.  of  nerv.  and  ment.  diseases 
1898,  p.   175,  Anal,  in  Gaz.  hebdom.   1899,  p.  82.) 


Diseases  of  the  Coi  d.  15 

responsibility  between  Romberg's  sign  and  the  state 
of  the  muscular  sense  and  that  in  certain  cases  of 
tabes  it  can  be  clearly  shown  that  Romberg's  sign  is 
present  when  it  is  impossible  to  make  out  the  least 
diminution  of  muscular  sense  by  the  most  delicate 
tests. 

The  excitations  from  the  muscles  (as  all  the 
others),  once  in  the  cord  divide:  some  provoke  me- 
dullary reflexes,  others  go  to  the  higher  centers 
where  they  produce  impressions  of  muscular  sense. 
The  first  may  be  alone  involved  in  the  lesion  of 
tabes  and  then  incoordination  and  Romberg's  sign 
are  found,  but  in  the  same  patient  the  second  may 
ascend  to  the  brain  and  the  muscular  sense  per- 
sist. 

It  is  in  this  way  that  cutaneous  reflexes  can  be 
abolished  when  the  tactile  sensibility  remains  intact. 

In  other  words,  in  the  intra-meduUary  conduc- 
tion the  reflex  paths  may  be  suppressed  without  the 
direct  paths  to  the  brain  being  interrupted  and  then 
ataxia  and  Romberg's  sign  are  present  without  neces- 
sarily a  disappearance  of  the  muscular  sense. 

This  is  so  true  that  the  tabetic  deprived  of  his 
medullary  automatic  gait  continues  to  walk  by  his 
brain.  And  as  in  the  cord  certain  fibres  can  take 
the  place  of  others^^  the  tabetic  can  reeducate  his 
cord  with  his  brain. 

This  explains  the  success  of  Frenkel's  method  in 
tabes. ^^ 

^*Dans  mon  Rapport  au  Congres  de  Moscou,  j'ai  cite  un 
fait  de  Erb  et  de  Schultze  dans  lequel  r  ataxic  a  giieri  sans 
que  la  lesion  dcs  cordons  posterieurs  ait  gueri ;  il  y  avait 
done  en  suppleance,  formation  de  nouvelles  voies  physiol- 
ogiques  dans  la  moelle. 

^^Voir  le  Rapport,  cite  ci-dessus,  sur  le  traitement  du 
tabes  in  Leg.  de  clin.  med.  1898,  3^  serie,  p.  634. 


1 6  The  Diagnosis  of 

Then,  and  in  conclusion,  incoordination  and 
Romberg's  sign  prove  only  a  change  in  the  posterior 
root  tracts  which  go  to  the  medullary  reflex  centers 
of  coordination  and  tonus.  The  muscular  sense  is 
affected  in  its  turn  when  the  lesion,  more  extensive^ 
involves  also  the  posterior  sensory  tracts  which  go 
to  the  higher  cerebral  centers. 

D.  For  each  syndrome  studied  by  us  the  dif- 
ferential diagnosis  consists  in  indicating  the  symp- 
toms by  which  the  medullary  origin  of  this  syn- 
drome is  recognized.  That  is  to  say,  the  symptoms 
which  differentiate  it  from  more  or  less  analogous 
syndromes  of  cerebral  (or  rather  intracranial),  peri- 
pheral (neuritic)  or  neurosic  origin. 

I.  Lesions  6f  the  cerebral  cortex  may  cause  sen- 
sory troubles  and  a  kind  of  ataxia,  which  here  is 
really  related  to  the  loss  of  the  muscular  sense. ^^ 
This  syndrome  differs  from  that  of  the  posterior 
columns  in  being  strictly  hemiplegic,  accompanied 
by  other  plainly  cerebral  svmptoms  (as  the  "stroke'* 
and  hemiplegia)  and  not  accompanied  by  symptoms 
plainly  medullary  spinal  (as  lightning-like  pains, 
sphincter  troubles  and  abolition  of  tendon  reflexes). 

By  the  same  class  of  differential  symptoms  may 
be  distinguished  lesions  of  the  opto-striate  bodies 
and  the  internal  capsule  which  also  can  produce  by 
anaesthesia  and  post-hemiplegic  chorea,  a  form  of 
ataxia.-^ 

The  cerebellar  syndrome  resembles  the  posterior 
cord  syndrome  in  many  points.  But  the  gait  of  the 
little  brain  is  intoxicated,  a  zig-zag,  reeling,  stagger- 
ing one  with   only  a  little  or  no  Romberg's  sign,  no 

^"Voir  Anesth.  d'orig.  cortic  in  Revue  de  med.  et  de  chir. 
1880,  no  2 ;  a  la  suite  du  travail  de  Tripier. 

^^Voir  notre  travail  siir  une  variete  non  decrite  de 
phenom.  posthemipl.  (forme  hemiatax.)  in  Progres  mid., 
13  nov.   1880. 


Diseases  of  the  Cord.  1 7 

lightning-like  pains,  no  sphincter  troubles ;  and  on  the 
contrary,  from  the  cephalic  lesion  there  are  vomit- 
ing and  other  symptorns  from  the  intracranial  vicin- 

2.  Peripheral  lesions  can  produce  pains  (more 
or  less  lightning-like)  anaesthesia,  abolition  of  ten- 
don reflexes,  but  not  ataxia  with  the  Romberg  sign, 
and  no  sphincter  troubles. 

3.  For  the  neuroses,  chorea  can  be  easily  distin- 
guished since  the  abnormal  movements  take  place  in 
repose  and  have  a  wide  range  (movements  in  repose 
being  rare  and  not  extensive  in  a  lesion  of  the  pos- 
terior columns). 

Hysteria  is  more  difficult  of  recognition  because 
it  can  simulate  tabes  and  more  often  still  is  associ- 
ated with  it.  The  distribution  of  the  anaesthesias, 
the  sphincter  troubles  and  the  various  symptoms  of 
the  neurosis  (stigmata,  attacks)  generally  permit 
the  diagnosis. 

2.  The  Syndrome  of  the  Antero-Lateral  Col- 
umns :  Paretospasmodic  State,  Contrac- 
tures and  Intention  Tremor/^ 

A.  The  constituent  clinical  elements  of  this  syn- 
drome are : 

I.  Contractures,  permanent,  variable  (sleep,  re- 
pose, chloroform,  Esmarch  bandage)  or  latent  (re- 
vealing themselves  in  voluntary  movements)  :  it  is 
the  type  of  the  manifestation  of  a  lesion  or  the  ab- 
sence of  the  pyramidal  bundles. 

^^Voir  nos  leg.  sur  les  contractures  et  la  portion  spinale 
du  faisceau  pyram.  (le  syndr.  paretospasm.  et  le  cordon 
lateral),  in  Nouveau  Montpellier  med.  1899,  Janvier  a  mars; 
et  une  Note  sur  les  contractures  et  la  portion  spinale  du 
faisceau  pyram.  in  Revue  neurol.  1899,  p.  122. 
2 


1 8  The  Diagnosis  of 

2.  With  the  least  intensity  and  less  limitation 
of  the  lesion  there  is  paresis  with  exaggeration  of 
the  tendon  reflexes  (patellar  tendon  reflex,  tendon 
Achilles  studied  by  Babinskij,  clonic  phenomena* 
(clonus  or  epileptoid  tremor  of  the  foot,  knee 
clonus)  the  phenomena  of  the  toes  (Babinskij,  ex- 
tension of  the  toes  on  excitation  of  the  sole  of  the 
foot.-^ 

3.  When  the  lesion  of  the  antero-lateral  columns 
leaves  some  fibres  intact  in  the  midst  of  the  sclero- 
sis, an  intentional  tremor,  typical  of  disseminated 
sclerosis,  absent  in  repose,  develops  on  action  and  is 
increased  by  a  repetition  of  the  act. 

B.  This  system  is  exclusively  attacked  and  in 
consequence  the  syndrome  is  pure  in  three  diseases : 
late  contractures  of  hemiplegics,  spasmodic  tabes, 
(ataxic  paraplegia),  and  Little's  disease. 

I.  Described  by  Suavages  among  paralytic  con- 
tractures, late  contracture  of  hemiplegics  is  sepa- 
rated from  the  early  contractures  by  Todd  (1856) 
and  joined  by  Charcot  and  Bouchard  (1866)  to  the 
descending  degeneration  of  the  pyramidal  bundle 
already  described  by  Cruveilhier  above  the  pyramids 
and  by  Turck  ( 185 1)  below.  Xext  comes  Brissaud's 
masterly  study  (1880). 

It  may  be  said  that  for  all  neurologists  (  we  shall 
discuss  in  a  paragraph  of  the  pathological  physi- 
ology the  opposed  opinion  of  van  Gehuchten)  the 
late  permanent  contracture  of  hemiplegics  with  ex- 

^^Nous  rapprochons  tous  ces  elements  dans  le  meme 
groupe  symptomatique,  malgre  les  publications  de  Maurice 
de  Fleury  (1884)  et  de  van  Gehucten  (1897). — Pour  rous 
ces  phenomenes.  voir :  Sternberg.  Die  Sehnenrefl.  u  ihre 
Bedeut  f.  d.  Pathol,  d.  Nervensystems,  Leipzig,  1893 ;  et 
Garnault.  Contrib.  a  I'et.  de  quelques  refl.  dans  I'hemipt. 
de  cause  organ.    Th.  Paris  1898. 


Diseases  of  the  Cord.  19 

aggeration  of  the  tendon  reflexes  is  the  syndrome  of 
a  lesion  of  the  pyramidal  fibres,  consecutive  to  one 
of  a  cerebral  center. 

2.  Spasmodic  tabes  has  been  more  discussed. 
-  Erb  and  Charcot  described  the  syndrome  in  1875 
under  the  name  of  spastic  spinal  paralysis  and  of 
spasmodic  tabes  dorsalis  and  attributed  it  to  a  lat- 
eral sclerosis  by  reasoning  from  analogy  only. 

The  first  autopsies  weakened  this  view.-*  Ley- 
den  from  the  beginning,  Raymond  from.  1885  and 
till  today  1898,  deny  this  anatomo-clinical  syn- 
drome. This  is  also  P.  Marie's  opinion  (1892)^ 
who  uses  the  word  only  for  the  infantile  forms  ( Lit- 
tle's disease) .  I  believe  on  the  contrary  with  Brissaud 
(1895)  that  spasmodic  tabes  exists  in  the  adult  with 
a  lateral  sclerosis  as  the  anatomical  substratum.  To- 
constitute  an  anatomo-clmical  syndrome  such  as  this 
it  is  necessary  that  there  be ;  clinically  always  the 
same  symptom  picture,  anatomically  a  lesion  of  a  con- 
stant location. 

But  aside  from  this  constant  lesion  there  may  be 
other  lesions,  variable  and  clinically  latent,  without 
suppressing  or  altering  the  clearness  of  the  type. 

Thus  Jean  Charcot  showed  that  Aran-Duchenne's 
progressive  muscular  atrophy  exists  without  an 
amyotrophic  lateral  sclerosis  even  when  the  lesion: 
is'  not  strictly  limited  to  the  anterior  horns  of  the 
grey  substance.  In  order  that  the  case  become  an 
amyotrophic  lateral  sclerosis  it  is  necessary  that  the 
lateral  lesion  should  be  so  important  that  it  does  not 
remain  latent. 

In  the  same  way  we  may  include  in  spasmodic 
tabes  some  cases  of  lateral  sclerosis  in  which  the  le- 

^*PiTRES  a  public  la  premiere  autopsie  d'un  tabes   spas- 
modiqiie  de  Charcot:   c'etait  une  sclerose  en  plaques. 


2  0  The  Diagnosis  of 

sion  extends  slightly  to  some  cellular  groups,  but 
without  amyotrophy,  or  to  the  tracts  of  GoU  and  to 
the  cerebellar  tracts  without  symptoms,  or  compli- 
cated by  absolutel}'  distinct  lesions  in  the  brain,  foi; 
instance. 

Applying  these  principles  to  the  criticism  of  the 
facts  published  during  the  last  years  we  will  retain 
a  great  number  of  observations  rejected  by  Ray- 
mond-^ and  will  say  with  Brissaud  "By  one  of  those 
revivals  always  necesssary  it  is  now  proved  to  us 
that  a  primar}-  sclerosis  of  the  lateral  columns  is  not 
a  myth.  It  really  exists,  and  it  is  necessary  to  go 
back  to  it  to  find  the  cause  and  to  conceive  the  path- 
ogeny of  a  great  number  of  cases  of  spasmodic 
tabes  dorsalis."  And  as  I  have  already  remarked 
elsewhere,  the  same  year  (1898)  where,  in  his  third 
volume  of  clinics,  Raymond  said  that  the  lateral 
theory  of  spasmodic  tabes  "has  been  completely  de- 
stroyed," his  interne  Lorrain,  under  him,  supported 
a  thesis  on  family  spasmodic  paraplegia,  which 
proves  that  the  destruction  of  this  theory  is  not  couit 
plete.  Then  there  is  a  second  group  of  very  clear  cases 
in  which  there  are  clinically  a  pareto-spasmodic 
state  and  contractures,  and  anatomically  lateral 
sclerosis. 

3.  Without  retaining  the  more  or  less  limited 
etymological  sense  of  the  word  I  reserve  by  the  ex- 
ample of  Brissaud  and  of  van  Gehuchten  the  name 

^°TeIs  sont  notamment  les  faits  de  Striimpell  (1879), 
Stoffela  (1878),  Morgan  (1881).  Aufrecht  (1880).  Min- 
kowski (1884).  Jubineau  (1883),  Westphal  (1884).— Voir 
aussi  la  these  de  notre  interne  d'alors,  Guibert  (Montpellier 
1892),  les  travaux  de  Jegorow  (1891)  et  de  Shiile  (1894), 
Ics  memoires  de  Striimpell  echelonnes  de  1880  a  1894,  les 
faits  cites  par  Brissaud  (1895),  celui  de  Dejerine  et  Sottas 
(1896)  et  la  Th.  de  Lorrain  (Contrib.  a  I'etude  de  la  parapl. 
spasm,   familiale  1898). 


Diseases  of  the  Cord.  2 1 

of  Little's  disease  for  cases  of  spasmodic  rigidity, 
observed  in  children  born  prematurely,  without  in- 
itial cerebral  phenomena,  and  anatomically  due  to 
the  absence  of  the  development  (at  the  time  of 
birth)  of  the  spinal  portion  of  the  pyramidal  tracts. 
I  eliminate  thus  from  the  group  not  only  infantile 
spasmodic  hemiplegias  but  all  infantile  cerebral  di- 
plegias.-^ 

In  these  cases,  thus  defined,  we  find  the  clinical 
syndrome  described  above,  and  anatomically,  not  a 
lesion,  but  an  absence  of  the  pyramidal  tracts. 

C.  Besides  these  three  diseases  the  whole  history 
of  which  is  made  up  of  the  anatomo-clinical  syn- 
drome studied,  we  find  this  same  syndrome  (with 
others)  in  a  certain  number  of  other  diseases. 

Such  is  first  disseminated  sclerosis :  In  this  dis- 
ease the  change  in  the  antero-lateral  columns  is 
shown,  1st,  by  the  characteristic  tremor,  an  inten- 
tion tremor,  originating  in  action  and  exaggerated 
by  the  repetition  of  an  act;  2nd,  by  the  pareto- 
spasmodic  phenomena  which  after  the  tremor  con- 
stitute the  most  frequent  and  most  characteristic 
symptoms  of  disseminated  sclerosis. 

When  a  diffuse  myelitis  or  a  compression  of  the 
cord  changes,  either  directly  or  indirectly,  by  second- 
ary descending  degeneration  the  pyramidal  fibres, 
we  find  also  the  syndrome  we  are  studying.  We  dis- 
cuss further  along  (in  chapter  2)  the  cases  of  flac- 
cid paraplegia  in  compression  of  the  cord  or  in 
transverse  myelitis. 

^^C'est  le  seul  moyen  de  ne  pas  faire  un  groupe  flou  sans 
caracteristique  clinique  ou  anatomique,  et  de  repondre  aux 
objections  de  Raymond,  qui  arrive  a  cette  conclusion  decour- 
ageante:  "Les  faits  demontrent  qua  I'heure  actuelle  il  nous 
est  impossible  d'etablir  un  rapport  fixe  entre  le  mode  de 
groupement  et  de  localisation  de  ces  symptomes  et  les  lesions 
constituees  a  I'autopsie.'' 


2  2  The  Diag7iosis  of 

Certain  symptoms  of  general  paralysis  (exag- 
geration of  the  tendon  reflexes,  tremor)  are  also  de- 
pendent upon  a  change  in  this  medullary  system; 

D.  After  all  has  been  said  and  after  what  I  ha^e 
developed  elsewhere,-!  believe  it  necesssary  to  keep 
the  law  I  promulgated  in  1877  ^'^^  1878  after  Char- 
cot and  Strauss  (1875)  and  to  say,  despite  the  op- 
position of  certain  authors,  notably  Raymond,  that 
the  permanent  contractures  of  the  pareto-spasmodic 
condition  of  medullary  origin  are  in  constant  rela- 
tion to  a  lesion  of  the  spinal  part  of  the  pyramidal 
fibres. 

But  the  pathological  physiology  of  the  syndrome 
remains  obscure. 

I.  With  Charcot,  Vulpian  and  Brissaud"^  (1875 
1880)  it  is  necessary  to  think  the  permanent  con- 
tracture due  to  a  permanent  muscular  hyperactivity 
by  an  exaggeration  of  tonus.  But,  to  explain  the 
exaggeration  of  tonus,  these  authors  admit  that 
there  must  be  a  lesion  of  the  pyramidal  fibres,  act- 
ing as  strychnia,  b}''  exciting  the  root  cells  (center 
of  tonus).     . 

To  the  second  part  of  their  theory  we  may  ob- 
ject: (A).  Sclerosis  of  the  pyramidal  fibres  should 
not  have  a  special  action  on  the  cells ;  posterior  scle- 
rosis should  have  the  same  result;  this  clinically  is 
not  so  ;  ( B ) .  We  cannot  comprehend  the  perma- 
nence of  an  exciting  action  exercised  by  a  sclerosis 
without  inflammatory  activity;  (C).  In  Little's  dis- 
ease one  cannot  comprehend  that  the  absence  of  the 
pyramidal  fibres  excites  the  cells  as  a  sclerosis  of  the 
same  bundle. 

It  remains,  then,  to  find  how  a  lesion  of,  or  the 

"'Je  ne  dis  rien  des  theories  de  Folin  et  Hitzig  qui  sont 
refutees  partont. 


Diseases  of  tJie  Cord.  23 

absence  of  the  pyramidal  fibres  produces  this  exag- 
geration of  tonus  shown  by  contracture. 

2.  Since  Adamki-ewicz  (1881J  it  has  been  ad- 
mitted that  tonus  is  submitted  to  a  higher  regulating 
action  formed  by  two  antagonistic  actions :  The  one 
inhibitory,  which  passes  by  the  lateral  columns,  the 
other  exciting,  which  the  same  author  makes  pass 
by  the  posterior  columns. 

From  this  notion  the  theory  of  Anton  (1890) 
and  of  Pierre  Marie  (1892)  follows. 

The  anterior  root  cell,  the  center  of  reflex  tonus 
is  a  machine  under  pressure ;  an  inhibitory  action 
exercised  by  the  higher  centers  normally  arrives  by 
the  pyramidal  fibres ;  when  the  pyramidal  bundles 
are  altered,  destroyed  or  absent  the  inhibition  is  sup- 
pressed, the  center  free  to  excitation  overacts ;  hence 
we  have  hypertonus  and  permanent  contracture. 

Here  we  have  an  advance  in  this  theory  over  the 
preceding.  But  it  is  open  to  a  serious  objection 
(van  Gehuchten)  :  This  theory  does  not  explain 
that  the  symptomatology  may  be  different  when  the 
lesion  affects  the  cerebral  portion  or  the  spinal  por- 
tion of  this  same  pyramidal  bundle,  that  in  the  first- 
case  there  is  paralysis,  in  the  second  contracture, 
that  after  a  cerebral  lesion  the  contracture  appears 
only  when  the  lesion  descending  has  become  sub- 
pontal  and  spinal. 

This  prime  objection  can  be  made  by  all  the 
authors  (Jackson,  Bastian,  Freund,  Raymond)  who 
locate  in  the  brain  (cortex)  the  origin  of  the  inhibi- 
tory action  transmittted  by  the  pyramidal  tracts  to 
the  anterior  root  cells. 

3.  Van  Gehuchten-^   (1896,  1898)  mentioned  a 

^^J'ai  essaye  de  montrer  ailleurs  que  la  theorie  de  Mya 
et  Levi    (1896},   adoptee  par  Gerest    (1898),  ne  resout  pas 

non  plus  la  question. 


24  The  Diagnosis  of 

new  element  useful  in  the  elucidation  of  this  ques- 
tion. The  inhibitory  action  of  tonus  comes  from  the 
higher  centers,  passes  indeed  by  the  pyramidal  fibres 
but  the  exciting  action  passes  by  the  indirect  pontp- 
cerebello-spinal  paths.  Whence  the  pyramidal  bun- 
dle is  differently  constituted  in  its  cerebral  and 
spinal  portions :  The  lesion  of  the  cerebral  portion 
causes  total  paralysis ;  that  of  the  spinal  portion,  in- 
volving only''  the  inhibitory  paths  of  tonus,  brings 
about  contracture.  This  explains  very  well  the  flac- 
cid paralysis  at  the  beginning  of  a  cerebral  lesion 
and  the  contracture  of  Little's  disease  or  of  lateral 
sclerosis  at  the  onset,  and  here  is  the  advance  over 
preceding  theories — but  this  does  not  explain  the 
late  contracture  of  the  hemiplegic,  it  does  not  ex- 
plain how  the  cerebral  paralysis,  flaccid  at  the  be- 
ginning, becomes  spastic  when  the  lesion  extends 
below  and  becomes  sub-pontal. 

Van  Gehuchten  understands  the  objection  and 
responding  to  it  admits  that  the  late  contracture 
of  the  hemiplegic  is  entirely  different  from  the 
medullary  contracture  at  the  onset  and  from  spas- 
modic contracture  ;  in  the  hemiplegic  the  exaggeration 
of  the  tendon  reflexes  is  related  to  the  pathogeny  of 
spasmodic  contracture,  but  the  permanent  contract- 
ure which  is  thus  separated  from  the  exaggeration 
of  the  tendon  comes  simply  from  the  fact  that  the 
extensors  are  generally  more  paralyzed  than  the 
flexors  and  so  these  less  opposed  by  their  antago- 
nists contract. 

Gerest  verv  justly  discussed  this  special  theory  of 
the  contracture  of  hemiplegics :  (A).  In  the  ex- 
tended cerebral  softening  there  is  not  this  unequal 
distribution  of  paralyses  and  yet  contracture  de- 
velops :  ( B ) .  It  is  not  understood  why  the  contract- 
ure develops  only  late  in  hemiplegics;  (C).    In  cer- 


Diseases  of  the  Cord.  25 

tain  cases  (neuritis  for  example)  the  paralysis  can 
be  very  unequally  distributed  and  yet  contracture  of 
the  least  paralyzed  doefe  not  follow. 

I  add  that  it  seems  to  me  absolutely  anti-clinical 
to  separate  the  contracture  of  hemiplegics  from  ex- 
aggeration of  tendon  reflexes  and  from  spasmodic 
contractures. 

The  pareto-spasmodic  syndrome  is  always  the 
same  in  its  symptomatic  expression  and  always  cor- 
responds to  the  same  location  of  the  lesion  whether 
it  is  cerebral  or  spinal;  a  single  thing  distinguishes 
one  from  the  other,  that  is  the  date  of  the  appearance 
of  the  contracture;  simply  because  contracture 
belongs  solely  to  spinal  and  because  the  cerebral  be- 
comes spinal  late,  while  the  spinal  is  spinal  from  the 
onset.  To  dissociate  the  contractures  of  hemiple- 
gics and  the  exaggeration  of  their  tendon  reflexes 
seems  to  me  equally  artificial  and  refuted  by  the 
clinic. 

Among  all  the  arguments  given  by  van  Gehuch- 
ten  to  oppose  the  contracture  of  hemiplegia  to 
spasmodic  contracture  a  single  one  is  impressive: 
in  the  spasmodic  form  tonus  is  diminished.  I  might 
be  contented  to  reply  that  this  seems  paradoxical 
with  all  the  theories  of  contractures  and  in  conse- 
quence with  Babinski  we  must  simply  describe  it  as 
"singular."  But  we  can  reply  more  peremptorily. 
In  a  recent  work  on  the  question  Marinesco  (1898) 
concludes :  "Even  admitting  that  Babinski's  con- 
clusions have  a  general  value  this  relaxation  ordi- 
narily exists  in  the  non-paralyzed  muscles,  not  in 
the  contracted  muscles. 

"The  result  is  that  in  no  way  should  we  conclude 
from  Babinski's  studies,  as  van  Gehuchten  has  done, 
that  the  contracted  muscles  of  the  hemiplegic  are 
found  relaxed." 


26 


The  Diagnosis  of 


Then  the  second  part  of  van  Gehuchten's  theory 
is  not  acceptable. 

But,  with  only  the  first  part  of  his  ideas,  we 
cannot  respond  to  the  objection  formulated  against 
all  the  theories  which  place  the  regulating  centeY  of 
tonus  in  the  cerebral  cortex.  Then,  we  have  not  vet, 
despite  all  our  accumulated  efforts,  a  satisfactory 
theor}'  of  the  relation  between  contracture  and  the 
pyramidal  tracts. 

A  Q  Cerebral  cortex 


aa 


O  Cerebellum 
C 


D  OSpinal  cord 


Fig. I. 

4.  The  failure  of  all  these  theories  to  refute  the 
last  objections  is  due  to  the  fact  that  all  place  the 
origin  of  the  inhibitory  or  controlling  action  exer- 
cised on  tonus  in  the  cerebral  cortex.  To  remove 
all  difficulties  it  is  necessary  and  sufficient  to  place 
the  higher  center  of  the  regulation  of  tonus  not  in 
the  cerebral  cortex,  but  lower  in  the  pons. 

Let  us  admit  for  a  moment  this  hypothesis.  Be- 
low in  A  (Fig.  i)  is  the  cortical  center  of  voluntary 
movements,  which  acts  on  the  tonus  when  we  wish 
lo  modify  this  reflex;  in  B  (in  the  pons)  is  the  cen- 
ter which  rules  automatic  tonus.     From  this  center 


Diseases  of  the  Cord.  27 

B  (as  from  center  A)  direct  fibres  ( Ijy  the  pyra- 
midal tract  J  go  toward  D  (spinal  center  of  reflex 
tonus  J  which  carry  'inhibitory  impulses,  and  in- 
direct fibres  (by  the  cerebellum  C)  which  carry  ex- 
citing actions. 

\\'hen  the  lesion  is  located  at  a  (cerebral  por- 
tion of  the  pyramidal  tract)  there  is  motor  paraly- 
sis :  the  orders  given  by  A  cannot  reach  D  either  by 
the  direct  or  indirect  fibres.  But  the  tonus  is  not 
affected  since  its  automatic  center  B  remains  in  nor- 
mal connection  with  D  by  the  two  classes  of  fibres, 
mhibitory  and  exciting.    Then,  no  contractures. 

When  the  lesion  is  located  at  b,  that  is  to  say 
the  spinal  portion  of  the  pyramidal  tract  is  attacked 
at  the  onset  or  finally,  the  tonus  is  no  longer  intact 
since  B  the  automatic  center  of  tonus  no  longer  com- 
municates with  D  by  the  inhibitory  paths  B  D  and 
still  communicates  with  it  by  the  exciting  paths  BCD. 

It  is  indeed  understood  that  the  symptomatology 
differs  according  as  to  whether  the  lesion  initially 
takes  place  above  or  below  aa  and  that  it  also 
changes  when  the  lesion  initially  above  a  finally  in- 
vades the  region  below  aa. 

Here  then  is  an  hypothesis  which  answers  all  the 
objections  :  it  consists  simply  in  placing  in  the  pons 
(B)  and  not  in  the  cortex  (A)  the  automatic  regu- 
lating center  of  tonus. 

This  hypothesis  is  not  unreasonable  physiologic- 
ally. 

The  cerebral  cortex  has  certainly  an  action  on 
the  reflexes  and  on  the  tonus :  the  proof  lies  in  the 
fact  that  w^e  can  modify  voluntarily  the  attitude  of 
our  body,  can  act  voluntarily  on  what  Barthez  calls 
the  force  of  the  fixed  position,  can  to  a  certain  limit 
control  the  sphincters. 

But  there  is  another  thing :  the  complex  reflexes 
as  tonus  have  an  automatic  rei?'ulatino-  center  and  it 


28  The  Diagfiosis  of 

is  from  this  center  that  the  inhibitory  and  exciting 
actions  we  are  studying  arise. 

This  automatic  center  is  entirely  distinct  from 
the  voluntary  center  (cortical)  as  it  is  distinct  from 
the  lower  simple  reflex  center  (spinal). 

We  maintain  some  attitudes,  even  complex  ones, 
entirely  without  voluntary  action  and  higher  con- 
sciousness. 

It  is  this  automatic  center  that  I  locate  in  the 
pons.  The  physiologists  have  made  some  experi- 
ments which  seem  to  establish  this  point. 

Vulpian  says,  'Tt  is  the  pons  which  presides  over 
the  normal  attitude  of  animals."  He  shows  a  very 
young  rabbit  and  a  pigeon  from  which  all  portions 
of  the  encephalpn  anterior  to  the  pons  have  been  re- 
moved, and  which  hold  themselves  in  the  normal 
attitude,  raising  themselves  if  they  are  put  on  the 
back  or  on  the  side.  A  fowl  thus  operated  upon  can 
hold  itself  on  one  foot  or  hide  its  head  under  its 
wing.  Alore  recently  Goltz  has  shown  a  frog  with- 
out a  brain  doing  "acrobatic  exercises ;  if  it  is  put 
on  a  plank  which  gradually  inclines  it  climbs  and 
passes  over  from  one  side  to  the  other  without  fall- 
ing." Two  dogs,  from  which  Goltz  had  extirpated 
the  greater  part  of  the  cerebral  hemispheres  ''were 
essentially  reflex  machines  eating  and  drinking." 
Hedon  who  reported  some  experiments,  concludes,^* 
"that  animals  deprived  of  the  brain  preserve  besides 
organic  functions  which  remain  intact,  various  fac- 
ulties which  may  be  classified  under  the  titles  of 
equilibration,  of  coordination  of  movements  and  of 
emotional  expression." 

These  various  experiments  show  that  the  regu- 
lating center  of  the  attitude  is  neither  in  the  cord  nor 

'''Hedon.    Precis,  de  physiol.  2©  edit.  1899,  p.  511. 


Diseases  of  the  Cord  29 

the  brain.  For  if,  in  the  frog  above  cited,  the  mu- 
tilation is  extended  and  a  part  of  the  bulb  is  re- 
moved the  tendency  toward  the  normal  attitude  im- 
mediately is  rendered  impossible.  Hence  the  center 
of  attitude  is  located  in  the  pons  or  at  least  in  the 
mesencephalon. 

But  some  say  (Brissaud)  that  the  contractures 
as  in  strychnia  poisoning,  only  exaggerate  and  im- 
mobilize the  attitude.  We  can  say  then  that  from 
this  pontal  (or  mesencephalic)  center  a  double  regu- 
lating action  on  tonus  arises,  an  inhibitory  by  the 
pyramidal  fibres,  and  an  exciting  by  the  ponto-cere- 
bellar  fibres. 

Then  the  contracture  of  spinal  origin  is  allied  to 
an  alteration  or  absence  of  the  pyramidal  fibres,  this 
alteration  determining  the  contracture  by  the  sup- 
pression of  the  inhibitory  action  on  tonus  which 
arises  from  the  pons  and  goes  to  the  root-cells  by 
the  pyramidal  fibres. 

E.  The  differential  diagnosis  needs  to  be  made 
only  from  neuroses  and  cerebral  lesions. 

For  the  neuroses,  paralysis  agitans  with  a 
tremor  (in  repose)  has  entirely  different  characters 
from  that  of  disseminated  sclerosis ;  hysteria  has  its 
stigmata  and  its  other  peculiar  symptoms  and  often 
has  contractures,  but  mobile,  fleeting  ones,  usually 
without  exaggeration  of  the  tendon  reflexes  and 
without  clonic  phenomena. 

When  the  contractures  are  of  cerebral  origin, 
they  are  early  if  from  a  local  lesion,  or  accompanied 
by  other  symptoms  either  of  a  tumor  or  of  an  acute 
or  subacute  encephalitis. 

Tetanus  or  strychnia  poisoning  and  intoxica- 
tions with  contractures  all  have  a  special  clinical 
history  which  easily  distinguishes  them  from  af- 
fections of  the  medullary  lateral  system  we  are 
studying. 


30  The  Diagnosis  of 

3.  The  Associated  Syndrome  of  the  Posterior 
and  Lateral  Colnnms:  Ataxo-spasmodic 
State. 

I  called  attention  (after  others)  to  this  anatomy- 
clinical  syndrome  in  1886^*^  and  the  very  title  of  my 
work  shows  I  did  not  wish  to  confound  this  that  I 
called  "combined  tabes"  with  what  has  been  called 
"combined  or  associated  sclerosis"  of  the  cord.  This 
latter  term,  purely  an  anatomical  one,  is  applied  to 
a  great  number  of  separate  cases  forming  hence  a 
confused  group. 

In  proportion  as  the  histological  technique  has 
been  perfected  more  and  more  accessory  lesions  have 
been  discovered  by  the  side  of  the  principal  lesion 
and  then  studying  the  combined  sclerosis^  we  con- 
clude, as  P.  Marie,  that  they  are  a  diffuse  group 
having  no  separate  existence. 

I  believe  that  it  is  good,  on  the  contrary,  to  re- 
serve the  name  of  combined  tabes  for  the  single 
complex  anatomo-clinical  syndrome  formed  by  the 
superposition  in  the  same  subject,  not  of  two  lesions, 
but  of  two  well  defined  anatomo-clinical  syn- 
dromes :  ataxic  tabes  with  its  posterior  sclerosis, 
and  spasmodic  tabes  with  its  lateral  sclerosis ;  that 
is  to  say  ataxo-spasmodic  tabes  with  postero-latei^l 
sclerosis.  Thus  defined,  the  group  is  very  clear, 
well  characterized,  as  all  the  anatomo-clinical  syn- 
dromes, at  the  time  bv  a  fixed  location  of  the  lesion. 

This  is  admitted  by  Brissaud  who  finds  "detest- 

^°Tabes  combine  (ataxo-spasmodique)  ou  sclerose  pos- 
terolater.  de  la  moelle.  Arch  .de  neurol.  1886,  t.  XI,  p.  156 
et  380;  t.  XII,  p.  27. — Voir  aussi  Tarbouriech.  Contrib.  a 
I'etude  du  tabes  combine.  Th.  de  Montpellier  1888,^  no  83, 
et  GuiEERT.  Et.  clin.  de  la  scler.  primit.  des  cord,  later  de  la 
moelle.     Th.  de  ^lontpellier,  1892,  no  23. 


Diseases  of  the  Cord.  31 

able"  the  word  combined  tabes  but  admits  what  lie 
calls  "ataxo-spasmodic  paraplegia"  if  not  as  a  special 
at  least  as  a  "definite  nosographical  variety." 

We  do  not  ask  more. 

Combined  tal^es  is  the  disease  which  is  exclu- 
sively manifested  by  this  anatomo-clinical  syndrome. 

Besides  this  other  diseases  may  also  have  this 
syndrome,  but  in  the  midst  of  others.  I  would  cite 
without  insisting  upon  them,  disseminated  sclerosis^ 
general  paralysis,  diffuse  myelitis  and  also  medullary 
arteriosclerosis  on  which  P.  Marie  has  insisted  with 
reason. 

There  is  nothing  to  say  of  the  pathological  physi- 
ology contained  in  the  two  preceding  paragraphs  nor 
of  the  differential  diagnosis  of  which  we  have  also 
analyzed  the  constituent  elements. 

4.    The  Syndrome  of  the  Anterior  Horns :  Mus- 
cnlar  Atrophy .^^ 

A.  In  two  important  groups  of  cases  the  lesions 
are  systematized  exclusively  to  the  anterior  horn 
cells  :  progressive  muscular  atrophy  (type  of  Aran- 
Duchenne)  acute  spinal,  atrophic  paralysis  (infan- 
tile and  adult).  We  add  to  these  certain  cases  of 
experimental  myelitis. 

I.  Clinically  discovered  by  Duchenne  (1849) 
and  by  Aran  (1851)  progressive  muscular  atrophy^ 
had  its  pathological  anatomy  fixed  by  all  the  French 
school  from  Cruveilhier  (1853)  to  Haven,  Charcot 
and  Vulpian. 

Then  from  this  classification,  initially  too  large, 
there  have  been  successively  removed  the  progres- 

^^Voir  nos  leg.  sur  trois  cas  d'atr.  muscul.  L'atr.  muscuL 
est  le  syndr.  du  neurone  moteur  central  (bulbomediill.)  in- 
ferieur,  in  Leg.  de  clin.  med.  1898,  3^  serie.  p.  793. 


32  The  Diagnosis  of 

sive  myopathies,  neuritis,  amyotrophic  lateral  scler- 
osis, syringo-myelia  and  P.  Marie  has  finished  by 
writing,  "Ihe  progressive  muscular  atrophy  of  Du- 
chenne  of  Boulogne"-  does  not  belong  there." 

This  was  an  exaggeration.  ^ 

As  we  have  said  above  a  propos  of  lateral  sclero- 
sis you  can  retain  in  a  given  classification  some 
cases  whose  lesion  is  not  strictly  limited  to  a  system 
provided  that  the  lesion  outside  of  the  system  is  ac- 
cessory, of  little  importance,  and  above  all  clinically 
silent. 

On  this  principle,  we  find  the  thesis  of  Jean 
Charcot,"^  observations  of  Strumpell,  Oppenheim, 
Dejerine,  Darkchewitsch  and  a  personal  experience 
(plus  one  more  recent  of  Raymond)^*  which  es- 
tablish histologically  the  existence  of  this  syndrome 
and  its  lesion.  Hoffman^^  equally  has  shown  that  in 
the  hereditary  amyotrophies  a  certain  part  should 
be  classed  as  the  Aran-Duchenne  type. 

Here  then  is  the  first  group  of  cases  the  exist- 
ence of  which  remains  indisputable,  characterized, 
clinically,  by  the  muscular  atrophy,  anatomically,  by 
a  lesion  of  the  anterior  horns  of  the  grey  substance. 

2.  It  was  still  Duchenne  who  fixed  the  clinical 


^^PiERRE  Marie.  Existe-t-il  une  atr.  muse,  progr.  Aran- 
Duchenne?   Revue  neurol.  1897,  t.  V,  p.  686, 

^^Jean  Charcot.  Contrib.  a  I'et.  de  I'atr.  muse,  progr., 
type  Aran-Duchenne.  Th.  Paris  1895. — Voir  aussi  Tzedep- 
OGOLU.  Th.  Montpellier  1892. 

^*Raymond.  Clin,  des  mal.  du  syst.  nerv.  1897,  2©  serie, 
p.  449. — Voir  aussi  Targowla.  Un  Job  moderne,  atr.  muse, 
du  type  Aran-Duchenne  chez  un  chemineau.  Nouv.  Inconog. 
de  la  Salpetr.  1897,  t.  X,  p.  415. 

^^HoFFMAN.  Ueb.  d.  progress,  spin.  Muskelatr.  in  Kin- 
desalter  aus.  famil.  Basis.  Deutsches  Zeitschr.  f.  Nervenh. 
1893,  t.  Ill,  p.  427  et  Weit.  Beitr.  z.  Lehre  von  d.  heredit. 
progr.  spin.  Muskelatr.  im  Kindesalter.  Ibid.  1897,  t.  X,  p. 
292.    (Trav.  de  la  clin.  d'Erb  et  du  labor,  d' Arnold). 


Diseases  of  the  Cord.  33 

description  of  infantile  spinal  atrophic  paralysis, ^*^ 
already  seen  by .  Underwood  ( 1 774) ,  Heine  ( 1840 ) , 
Rilliet'and  Barthez  ( 1851 )  :  after  an  acute  period  of 
generalized  paralysis  the  disease  is  localized  in  some 
muscular  groups  and  is  manifested  exclusively  by 
an  atrophy. 

Vulpian  and  Prevost  (1866)  were  the  first  to 
localize  the  lesion  in  the  anterior  horns  of  the  grey 
substance.  A  localization  confirmed  by  Lockhart, 
Clarke  (1867),  Charcot  and  Joffroy  (1870). 

Duchenne  had  already  seen  that  the  same  dis- 
ease mav  develop  in  the  adolescent  and  the  adult, 
and  all  the  later  works  have  confirmed  the  existence 
of  an  acute  spinal  paralysis  of  the  adult,  clinically 
and  anatomically  identical  with  that  of  the  infant. 

3.  Experimentally'^'  with  old  cultures  of  the 
streptococci  of  erysipelas  Rogers  (1891)  was  "able 
to  reproduce  in  six  animals  a  system  myelitis 
characterized  from  an  anatomical  point  of  view  by 
a  degeneration  of  the  anterior  horn  cells ;  from  the 
symptomatic  point  of  view  by  an  ensemble  of  phe- 
nomena comparable  to  progressive  muscular  at- 
rophy." 

Some  analogous  results  have  been  obtained  by 
Gilbert  and  Lion  (1891)  with  the  coli-bacillus, 
Bourges  ( 1893)  with  the  erysipelococcus,  Thoinot 
and  Masselin  (1894)  with  the  coli-bacillus  and  the 
staphylococcus. 

B.  But  it  does  not  seem  necessary  to  dwell  on 
the  diseases  which  attack  the  anterior  horns  without 
being  exclusively  localized  there :  it  suffices  to  say 

"''Voir  les  theses  de  Duchenne  fils,   Montpellier,   1864, 
no  8;  et  Laborde,  Paris  1864,  no  163. 

^'Voir   notre   Rapport  au   Congres   de  Bordeaux   sur  les 
Myel.  infect.,  in  Leg.  de  clin.  med.  1898,  36  serie,  p.  540. 
3 


34  The  Diagnosis  of 

that  when  the  anterior  horns  are  thus  attacked,  clin- 
ically there  will  be  muscular  atrophy. 

This  is  what  happens  notably  in  certain  compli- 
cated cases  of  tabes,  in  certain  syringo-myelias,  in 
certain  old  hemiplegias  with  descendmg  degenera- 
tions, in  certain  abnormal  cases  of  disseminated 
sclerosis,  in  pachymeningitis. 

C.  The  synthesis  of  the  syndrome  of  the  anterior 
horns  is  all  made  since  it  is  reduced  to  amyotrophy, 
and  the  pathological  physiology  does  not  require 
discussion :  it  is  the  expression  of  a  trophic  action 
exercised  on  the  muscle  by  the  cell  bodies  of  the 
central  inferior  motor  neurone. 

D.  Differential  diagnosis.  It  is  necessary  first 
to  eliminate  the  neurosic  origin  of  amyotrophy 
when  it  is  met. 

Since  Babinski's  memoir^^  the  facts  concerning 
hysterical  muscular  atrophy  have  been  multiplied 
but  in  these  cases  (very  rare,  moreover),  there  are 
no  fibrillary  twitchings,  no  reaction  of  degeneration, 
and  there  are  other  symptoms  of  hysteria. 

The  truly  diagnostic  difficulty  consists  in  distin- 
guishing spinal  amyotrophies  from  neuritic  amyo- 
trophies, and  from  myopathic  amyotrophies.  (The 
brain  by  itself  does  not  cause  muscular  atrophy). 

In  neuritic  amyotrophies  the  distribution  of  the 
atrophy  is  that  of  one  or  more  nerves,  the  paresis  or 
paralysis  is  more  marked,  there  are  pains  (spon- 
taneous and  on  pressure  of  the  nerve  trunks),  the 
tendon  reflexes  are  diminished  or  lost,  the  etiology 
is  a  special  one  and  retrocession  frequent. 

In  myopathies  there  are  no  fibrillary  twitchings. 
tendinous   retractions   are   frequent,   no   reaction   of 

^^Babinski.  De  I'atr.  muscul.  dans  les  paral.  hyster.  Arch, 
de  neuvol.  1886.  Voir  Gilles  de  la  Tourette.  Traite  din. 
et  therap.  de  I'hyst.  1895,  t.  IT,  p.  5C3- 


Diseases  of  the  Cord.  35 

degeneration,  begins  more  frequently  at  the  extrem- 
ity of  a  limb,  often  there  is  a  family  history  of  the 
same. 

5.  The  Associated  Syndrome  of  the  Lateral 
Column  and  the  Anterior  Horns :  Spastic 
Muscular  Atrophy. 

From  1865  Charcot  observed  a  sclerosis  of  the 
lateral  tracts  in  amyotrophy  and  with  Joffroy 
(1869- 1 879), described  amyotrophic  lateral  sclerosis 
(Charcot's  disease)  which  is  thus  clinically  defined: 
''a  progressive  paresis  of  certain  muscles,  at  times 
followed  by  atrophy  and  more  often  by  contractures 
of  these  muscles  or  by  phenomena  analogous  to  this 
contracture"  as  the  rigidity,  more  or  less  difficult 
to  overcome,  the  tremor  in  certain  cases ;  then  we 
should  add  the  exaggeration  of  the  tendon  reflexes 
and  the  clonic  phenomena. 

Anatomically  there  is  in  the  cord  (let  us  not  con- 
cern ourselves  here  with  the  medulla  nor  with  the 
brain)  a  lesion  of  the  anterior  horns  as  in  progres- 
sive muscular  atrophy  and  an  alteration  of  the  pyr- 
amidal fibres  as  in  descending  degenerations.  P. 
Marie"^  and  Brissaud  have  shown  that  there  is  also 
a  lesion  of  the  mass  of  the  antero-lateral  fibres  and 
especially  of  the  short  fibres  called  the  fibres  of  the 
cells  of  the  cord,  which  put  the  various  segments  of 
the  cord  in  relation  with  each  other.  This  lesion  of 
the  intramedullary  relay  neurones  plays  perhaps  a 
considerable  role,  if  not  an  exclusive  one  (Brissaud, 
Gerest)  in  the  production  of  amyotrophic  lateral 
sclerosis.     This  completes,  without  disturbing,  the 

•^°PiERRE  ^Iarie.   Leg.  citees,   1892  et  Soc.  med.  des  hop. 
1893,  dec. 


36  The  Diagnosis  of 

first  notion  of  the  anatomo-clinical  syndrome  we 
are  studying,  the  pyramidal  lesion  remaining  more- 
over "much  the  more  salient"  (Marie). 

A  single  case  constitutes  a  real  exception  in  this 
group;  it  is  that  of  Senator  (1894)  :  a  clinical  pic- 
ture of  amyotrophic  lateral  sclerosis  and  no  lateral 
sclerosis  on  autopsy.  But  this  observation  remains 
isolated  and  is  incomplete  since  the  brain  was  not 
examined. 

If  amyotrophic  lateral  sclerosis  manifests  itself 
exclusively  by  this  anatomo-clinical  syndrome  this 
same  syndrome  may  also  be  found,  more  or  less  as 
an  episode  in  other  maladies  as  diffuse  myelitis,  dis- 
seminated sclerosis,"**^  etc. 

Th^re  is  nothing  to  say  of  the  pathological 
physiology  and  the  differential  diagnosis  which  has 
not  been  said  in  paragraphs  2  and  4. 

6.  The  Syndrome  of  the  Ceiitro-posterior  Grey 
Substance:  Dissociation  of  Sensation 
called  Sj ringo-myelic  (and  Taso-motor 
Troubles). 

A  and  B.  This  syndrome  has  been  studied  in 
syringo-myelia,  where  perhaps  it  is  found  most  fre- 
quently. 

But  it  is  certainly  also  found  in  other  cases  and 
the  expression  syringo-myelic,  for  this  dissociation 
of  sensibilities  preserves  an  error  if  taken  literally. 

Named  by  Ollivier  of  Angers  {  1827)  syringo- 
myelia is  an  anatomical  condition  (known  since 
1688)  characterized  by  the  presence  in  the  cord  of 
abnormal  cavities.    We  say  there  is  a  hydro-myelia 

*°Voir  notamment  le  fait  recent  de  Brauer.  Neurol, 
Centralhl.  1898,  p.  638.  et  Revue  nenrol.  i8q9,  p.  22. 


Diseases  of  the  Cord.  37 

(the  analogue  of  hydrocephalus)  when  there  is  a 
dilation  of  the  central  canal. 

Developing  Grimm's  ideas  ( 1869)  Simon 
(1874),  and  Leyden/(i876)  Roth^^  in  a  series  ot 
works  since  1882  and  Dejerine*-  in  1889  have  at- 
tributed syringo-myelia  exclusively  to  a  medullary 
gliosis  and  have  considered  the  two  expressions  as 
synonyms.  But  giving  the  ideas  of  Hallopeau 
(1870)  in  detail  and  of  Charcot  and  Joffroy  (1869) 
Joffroy  and  Achard"^"  and  others  have  shown  that 
syringo-myelic  cavities  can  have  a  myelitic  origin 
also,  and  Souza  Martins*^  has  shown  that  it  may 
equally  be  observed  in  lepra.  On  the  other  hand, 
medullary  gliomatosis  may  evolve  without  produc- 
ing cavities.  The  synonymousness  then  of  the  two 
must  be  refused  and  the  word  syringo-myelia  must 
keep  its  original  anatomical  meaning.*^ 

The  principal  symptom  of  syringo-myelia  is  the 
following,  dissociation  of  sensation,  analgesia  and 
thermo-ansesthesia  with  preservation  of  tactile  sen- 
sation. Kahler*^  and  Schultze*^  first  diagnosticated 
a  syringo-myelia  by  this  symptom.  The  thing  be- 
came classic. 

With  Roth  and  Dejerine  this  syndrome  has  been 

*'RoTH.  Arch,  de  neurol.  1887-89,  nos  42  et  suiv. 

*-De,jerine.  Soc.  med.  des  hop.,  22  fevr.   1889. 

"JoFFROY  et  AcHARD.  De  la  myel.  cavitaire.  Arch,  de 
physiol.   1887. 

**SouzA  Martins.  Un  caso  de  syringom.  depend,  della 
labra.  Anal,  in  Revue  neurol.  1894,  P-  307. 

■'''Brissaud,  qui  a  bien  etudie  la  dissociation  ''syring- 
omyelique"  dans  la  pachymeningite  cervicale  hypertrophique 
(Leg.  sur  les  mal.  nerv.  1895,  p.  196)  et  cite  les  cas  avec 
autopsie  de  Joffroy,  de  Pierret  et  de  Koeler,  les  considere 
comme  des  exemples  de  gliomatose  consecutive,  secondaire. 

^'^Kahler.  Prag.  med.   Wochenschriii,  1882  et  1888. 

*'ScHULTZE.  Virch.  arch.  1882,  et  Zeitschr.  f.  klin.  Med., 
t.  XIII. 


38  The  Diagnosis  of 

completely  limited  to  this  lesion  and  the  qualifica- 
tion "syringo-myelic  has  been  given  to  this  disso- 
ciation of  sensation. 

Thus  this  symptom  has  become  an  absolute  sign 
of  syringo-myelia  superior  even  to  the  anatomical 
facts.  Thus  Dejerine  insisted  to  Joffroy  that  he 
had  observed  a  true  syringo-myelia  (although  it  was 
at  the  autopsy)  unique  because  the  patient  had  not 
presented  the  dissociation  called  syringo-myelic. 

I  believe  that  I  was  one  of  the  first^^  to  protest 
(1889)  against  this  view  which  reversed  all  that  is 
known  of  the  semeiolog}'  of  the  nervous  system. 
All  the  symptoms  known  are  in  relation  with  the  lo- 
cation of  the  change;  only  this  would  have  ex- 
pressed not  the  location  but  the  anatomical  nature 
of  the  change.     This  would  be.  improbable. 

To  support  my  protest  I  have  collected  two 
orders  of  proofs  which  I  will  recall,  adding  to  them 
the  documents  prepared  since  then,  which  have  sin- 
gularly confirmed  and  rendered  definite  the  thesis 
under  discussion. 

I.  Syringo-myelia  can  exist  without  the  syn- 
drome of  dissociation. 

I  have  cited  a  personal  experience  observed  with 
my  colleague  Carrieu.  Since,  out  of  66  cases  with 
clinical  and  autopsy  observations,  referred  to  in 
Anna  and  Baumler's  thesis  (1887)  I  found  55  in 
which  there  was  neither  the  entire  syndrome  nor 
any  of  the  constituent  elements  of  the  syndrome 
(and  this  is  also  in  gliomatosis  and  lacunar  my- 
elitis). 

Since  then  proofs  of  this  first  proposition  have 

**Voir  nos  leg.  sur  le  Syndr.  bulbomedull.  constitue  par 
la  thermanesth.,  I'analg.  et  les  troub.  sudor,  ou  vasomot. 
(subst.  grise  lateroposter.),  in  Montpellier  med.  aout  1889 
et  Leg.  de  clin.  med.  1891,  i^e  serie,  p.  186. 


Diseases  of  the  Cord.  39 

accumulated.  First  there  is  the  observation  of  Jof- 
froy  and  Achard*^  on  syringo-myeHa  demonstrated 
on  autopsy  and  having  produced  total  anaesthesia 
without  any  dissociation. 

Then  Rosenblath^^  published  two  cases  of  syr- 
ingo-myelia  (with  autopsy)  without  sensory 
troubles  or  at  least  without  dissociation ;  Preobra- 
jensky,^^  a  case  of  syringo-myelia,  not  gliomatous : 
total  anaesthesia  without  dissociation.  Dimitroff^^ 
began  an  important  work  on  syringo-myelia  with  an 
observation  of  his  own  without  sensory  troubles. 
Dejerine  and  Thomas^^  have  observed  a  recent  case 
without  sensory  troubles. 

In  the  great  monograph  of  Schlesinger^^  ( 1895) 
may  be  found  a  number  of  details  on  abnormal  types 
of  syringo-myelia  and  finally  Raymond^^  has  many 
times  insisted  on  the  clinical  polymorphism  of  this 


*®JoFFROY  et  AcHARD.  Un  cas  de  mal  de  Morvan  avet 
aut.  Arch,  de  med.  experim.  1890,  p.  540. 

^"RosENBLATH.  Z.  Casuist.  d.  Syringom.  etc.  D.  Arch. 
f.  klin.  Med.  1893,  t.  LI,  p.  210  {Revue  neurol.  1894,  p.  11). 
Trav.  de  la  clin.  med.  de  Leipsig. 

^^Preobrajenski.  Mem.  med.  1894.  (Revue  neurol.  1895, 
p.  75). 

^"Stephan  Dimitroff.  Ueb  Syringom.  (Trav.  de  la  clin. 
med.  du  prof.  Eichhorst  a  Zurich),  Arch.  f.  Psych.  1896, 
t.  XXVIII,  p.  582  et  1897,  t.  XXIX,  p.  299 :  fait  suite  au 
travail  dAnna  Baiimler,  et  analyse  297  observ.  (jusqu'en 
octobre  1891). 

^^Dejerine  et  Thomas.  Un  cas  de  syringom.  type  scapu- 
lohumer.  avec  integr.  de  la  sensibil.,  suivi  d'aut.  (integr.  de 
la  subst.  grise  mediane).  Soc.  de  hiol.,  10  juillet  1867,  {Re- 
vue neurol.   1898.  p.   153. 

"^ScHLESiNGER.  Die  Syringomyelic  (trav.  de  la  3^  clin. 
med.  et  de  I'lnstitut  d'anat,  et  de  physiol.  des  centr.  nerv. 
a  rUnivers.  de  Vienne).  Leipsig  et  Vienne  1895.  (526  in- 
dicat.  bibliogr.  classees  par  ordre  .alphabet  d'auteur). 

^^Raymond.  Clin,  des  mal.  du  syst.  nerv.  1896,  t.  I,  p. 
315  et  2>V,  et  1897,  t.  II,  p.  580  et  516. 


40  The  Diagnosis  of 

disease.  This  last  author  insists  especiahy  on  the  fre- 
quency of  the  total  anaesthesia  (non-dissociated) 
in  syringo-myelia  and  cites  the  findings  of  Miura 
(1889),  Rumpf  (1889),  Hochhaus  (1891),  Homen 
(1894J,  Oppenheim  (1893J,  Schuppel.  He  cites 
also  some  reports  of  syringo-myelia  in  the  form  df 
disseminated  sclerosis  (Brutton,  Rosenblath)  then 
reports  a  form  of  spasmodic  tabes :  Strumpell 
(1880),  Kahler  (1882),  Reisinger  and  Marchand 
(1884),   Schlesinger   (obs-7),  Raymond   (1893J. 

The  demonstration  of  our  first  proposition  is  then 
well  established  :  syringo-myelia  can  exist  without 
the  syndrome  of  dissociation. 

2.  The  dissociation  syndrome  can  exist  zvithout 
syringo-inyelia. 

Morvan  described  (1883),  under  the  name  of 
analgesic  panaritia,  paresis  of  the  upper  extremities, 
a  disease  which  bears  his  name  and  in  which  one 
often  finds  the  dissociation  syndrome.  Gombault 
and  Reboul  (1889)  made  an  autopsy  on  one  of  the 
patients  of  Morvan  with  dissociation.  They  found 
a  neuritis,  a  myelitis,  but  no  medullary  lacuna. 

In  1889  I  declared  the  principle,  although 
unique,  and  expressed  the  conviction  that  "Similar 
cases  existed  and  would  multiply  themselves  when 
attention  v/as  directed  to  this  point."  This  has  been 
largely  realized. 

First  Charcot'^^  found  syringo-myelic  dissocia- 
tion in  hysteria,  in  lepra  (Leloir,  Babinski,  Thi- 
bierge)  and  in  compression  of  the  cord^'  or  of 
nerves    (Critzman).    Minor''^   described  it  in  many 

^**Charcot.    Leg.  du  mardi  1889,  p.  517.       _ 

"Charcot.     Un   cas    de  pseudosyringom.    in   Seni.   med. 

1891,  p.   193- 

^^MiNOR.  De  rhematom.  centr.  Soc.  de  neurol.  et  de 
psych,  de  Moscou,  17  dec.   1893  et  Rech.  clin.   et  anat.  sur 


Diseases  of  the  Cord.  41 

cases  of  traumatic  haemato-myelia.''^  Freund^'* 
carefully  studying  sensory  troubles  in  disseminated 
sclerosis,  described  ''syringo-myelic"  dissociation  in 
ten  observations  of  this  disease  (with  peculiar  char- 
acter of  less  duration  than  in  true  syringo-myeha). 

In  1892  apropos  of  a  personal  case  at  Brissaud, 
Jean  Charcot'^^  studying  "the  dissociations  called 
syringo-myelic  in  compressions  and  section  of  nerve 
trunks,"  recalls  the  fact  that  diverse  dissociations 
.are  found  in  diseases  of  the  skin,*'-  (psoriasis,  ec- 
zema) and  again  finds  true  dissociation  in  a  series 
•of  cases  of  section  or  compression  of  nerves  (Letie- 
vant,  Weir  Mitchell,  Richet,  Chaput,  Blum ) . 

More  recently  Cavazzani  and  Manca*'"  have 
found  this  same  dissociation  after  a  traumatic  sec- 
tion of  the  radial  nerve.  And  the  same  year  ( 1895) 
Brissaud*'^  was  able  to  say:  "The  clinic  has  in- 
structed us  on  the  pretended  pathognomonic  value 
of  syringo-myelic  dissociation." 

This  dissociation  of  sensibility  no  longer  per- 
tains to  a  single  disease."  And  he  cites  a  case  of 
Brown- Sequard    with    dissociation    cured    by    anti- 

les  aft',  traumat.  de  la  moelle  suivies  d'hematom.  centr.  et  de 
format,  cavitaires  centr.  Congres  de  Moscou  1897  {Revue 
neurol.   1894,  p.  212  et  1897,  p.  549). 

^^Voir  Verchere.  De  la  paresie  analges.  a  panaris,  des 
€xtrem,  super.  De  la  paresoanalg.  des  extrem  super,  ou 
mal  de  Morvan.    Revue  des  sc.  med.  1891,  t.  XXXVIII,  p. 

324- 

''"Freund  (de  Breslau).  Ueb.  d.  Vork.  von  Sensibili- 
tatsstor  bei.  mult.  Herdskler  (trav.  de  la  clin.  du  prof. 
Westphal).  Arch.  f.  Psych.  1891,  t.  XXII,  p.  317  et  588. 

"Jean  Charcot.    C.  R.  de  la  Soc.  de  Biol.  1892.  p.  941. 

*-Rendu.    Les  anesth.  spont.  Th.  d'agreg.    Paris.  1875. 

^^Cavazzani  et  Manca.  Alteraz.  della  sensibil.  termice 
€  tattile  in  seg.  a  les.  del  nervo  rad.  Rif.  med.  1895,  no  57 
{Revue  neurol.  1895,  p.  534). 

^'■'Brissaud.  Leg.  sur  les  mal.  nerv.  1895. 


42  The  Diagnosis  of 

syphilitic   treatment   and    in   consequence      without 
syringo-myelia. 

In  1896  Max  Laehr^^  reported  a  series  of  facts 
of  "syringo-myeHc"  dissociation  in  some  cases  of 
the  Brown-Sequard  syndrome  without  syringo- 
myeha,  especially  those  of  Muller  (1871),  of  Char- 
cot and  of  Gombault  (1873)  Gowers  {traumatic 
hemorrhage)  Beevor  (syphilitic  tumor),  Steel  and 
Williamson  (1893). 

The  same  year  Schlesinger^^  published  a  case 
(and  calls  attention  to  three  other  personal  cases) 
of  intramedullary  tumor  (without  syringo-myelia) 
with  dissociation. 

Hanot  and  Henri  Meunier®'  observed  an  analo- 
gous syphilitic  gumma.  There  is  also  a  case  of  dis- 
sociation by  syphilitic  meningo-myelitis  which  Pia- 
ott  and  Cestan^^  published,  while  David  EdsalP® 
studied  the  dissociation  of  sensibility  of  a  syringo- 
myelic type  in  Pott's  disease,  and  which  James  Hen- 

*"'Max  Laehr.  Ueb  Storr.  d.  Schmerz-Temperatur.  Emp- 
find.  in  F.  von  Erkank.  d.  Riickenm.  (Klin.  St.  mit  besond. 
Beriicksicht.  d.  Svringom.)  Trav.  de  la  clin.  du  prof.  Jolly. 
Arch.  f.  Psych.  1896,  t.  XXVIII,  p.  772>. 

•'''ScHLESiNGER.  Tumeur  medull.  (Gliosarc.  de  la  reg. 
cervic.)  Club  med.  Vien.,  22  Janvier  1896.  {Revue  neurol. 
T896,  p.  441). 

'''Hanot  et  Henri  Meunier.  Gomme  syphilit.  double  de 
la  moelle  epiniere  ayant  determ.  un  syndr.  de  Brown-Seq. 
bilat.  avec  dissociat.  syringomyel.  Nouv.  Inconogr.  de  la 
Salpet.  1896,  p.  49  (meme  cas  commun.  par  Henri  Meunier 
au  Congres  de  I'A.  F.  A.  S.  a  Carthage  1896.) 

I^^TiATOT  et  Cestan.  Syndr.  de  Brown-Seq.  avec  dis- 
sociat. syringom.  d'orig.  syphilit.  Ann.  de  d ennatol.  iSgy,  p. 
713  et  Revue  neurol.  1897,  p.  645. 

^^David  Edsall.  Soc.  neurol.  de  Philadelphie,  20  dec. 
1897.  The  Journ.  of  nerv.  a.  ment.  Dis.  1898,  p.  257  et  Re- 
vue neurol.  1898,  p.  742. 


Diseases  of  the  Cord.  43 

drie  Lloyd '*^  demonstrated  in  traumatism  of  the 
cord. 

In  a  work  inspired  by  Marinesco,  Vines^^  shows 
''that  syringo-myeHc  dissociation  is  not  a  rare  symp- 
tom in  various  cases  of  chronic  myeHtis."  Dejerme 
and  Thomas"-  have  observed  dissociation  in  a  case  of 
hypertrophic  gummatous  pachymeningitis. 

And  Raymond^^  recently  has  written :  "It  is  not 
very  long  ago  that  dissociated  anaesthesia  was 
thought  to  pertain  properly  to  syringo-myelia.  A 
sort  of  pathognomonic  signification  was  attributed 
to  it.  Today  it  is  recognized  that  this  variety  of 
anaesthesia  is  observed  in  very  diverse  pathological 
circumstances.    It  seems  natural  this  should  be  so. 

If  a  gliomatous  tumor  or  any  other  neoplasm 
can  produce  these  symptoms  by  interrupting  the 
conductors  of  sensibility  it  is  easily  conceived  that 
the  lesion  may  be  of  any  nature,  a  hemorrhage, 
focus   of   softening,    or   an   islet   of    sclerosis,'^    the 

'°James  Hendrie  Lloyd.  Traumat.  aff.  of  the  cerv.  reg. 
of  the  Spin.  cord,  simulat.  Syringom.  The  Journ.  of  nerv. 
a.  ment.  dis.  1894,  p.  343  (Revue  neurol.  1894,  p.  450)  :  his- 
toire  clinique  de  deux  cas. — A  Study  of  the  los.  in  a  case  of 
trauma.  Brain.  1898  {Revue  neurol.  1898,  p.  613)  :  autop- 
sie  de  I'un  des  deux  faits  precedents. 

'^ViNES.  Despe  dissociationen.  Romania  medicala,  1898 
p.  122  Anal,  par  Marinesco  in  Revue  neurol.  1898,  p.  850. 

'"Dejerine  et  Thomas.  Un  cas  d'hemiparapl.  avec  an- 
esth.  croisee.  Syndr.  de  Brown-Seq.  suivi  d'aut.  Arch,  de 
physiol.   1898,  p.  594. 

'"Raymond.  Qin.  des  mal.  du  jyst.  nerv.  1897,  t.  II, 
p.-  549- 

^*C'est  la  pensee  qu'ont  egalement  enoncee  Hanot  et 
Meunier,  dans  leur  travail  deja  cite  de  1896:  ''...Quoi  de 
plus  nature!,  des  lors,  qu'une  pareille  lesion,  equivalant 
physiologiquement  a  une  lacune  syringomyelique  ait  deer- 
mine  la  dissociation  des  sensibilites,  telle  qu'on  le  recontre 
dans  les  cas  de  gliomatose  medullaire?" 


44  ^/^^  Diagnosis  of 

symptoms  will  be  the  same  in  all  cases  as  facts 
prove." 

We  can  then  affirm  as  demonstrated  today  the 
proposition  which  we  supported  in  1889  on  a  single 
disputable  case:  the  syndrome  dissociation  can  exist 
zi'ithont  syvingo-niyelia. 

C.  From  all  that  precedes  it  results  that  the  ana- 
tomical unity  of  the  dissociation  syndrome  is  not 
made  by  the  presence  of  medullary  gliomas,  nor  by 
the  presence  of  medullary  cavities  nor  by  the  pres- 
ence of  a  single  constant  medullary  lesion,  but  that 
for  this  syndrome  as  for  all  other  medullary  symp- 
toms, the  unity  is  only  made  by  the  unity  of  the  lo- 
cation of  the  lesion.  It  is  necessary  then  to  seek 
now  what  the  unique  and  constant  location  of  the 
lesion  is  corresponding  to  this  dissociation  syn- 
drome. We  shall  thus  come  to  the  pathological 
physiology  of  this  syndrome. 

In  the  medullary  sensory  system  it  is  not  a  lesion 
of  the  posterior  columns  which  gives  rise  to  our  syn- 
drome. For  in  the  syndrome  of  the  posterior  col- 
umns (which  we  have  already  studied  above)  there 
is  total  anaesthesia  or  if  there  is  dissociation  it 
is  tactile  anaesthesia  and  especially  muscular  which 
dominates  with  persistence  and  often  exaggeration 
of  the  sensation  of  pain  and  temperature.  This  is 
then  an  inverse  dissociation  and  in  a  manner  comple- 
mentary to  the  dissociation  called  syringo-myelic. 
Further,  in  many  observations  with  very  distinct 
"syringo-myelic"  dissociation,  the  integrity  of  the 
posterior  columns  is  noted  and  in  observations  of 
syringo-myelia  with  total  anaesthesia  there  has  been 
noted  on  the  contrary  a  participation  of  the  posterior 
columns  in  the  lesion. 

In  every  case  of  syringo-myelic  dissociation  the 
alteration  is  in  the  posterior  horns  of  the  grey  mat- 
ter. 


Diseases  of  the  Co?-d.  45 

We  have  indeed  cited  some  cases  in  which  the 
dissociation  appeared  to  respond  to  a  lesion  of  the 
peripheral  nerves.  But  then  it  is  permissible  to 
suppose  that  the  neuritic  lesion  has  extended  to  the 
medullary  centers  as  in  Marinesco's'-'  case.  It  may 
also  be  said  that  "There  are  distinct  points  on  the 
skin  for  tactile  and  thermal  sensibility."'®  But  for 
our  study  it  is  sufficient  to  say  that  zvhen  the  so- 
called  syringo-myelic  dissociation  is  due  to  a  medul- 
lary lesion,  the  change  is  in  the  posterior  horns  of 
the  grey  matter. 

This  is  the  clinical  conclusion  zvhicli  is  the  same 
as  in  1889.''  Physiologically  the  question  has  ad- 
vanced less. 

Moreover,  I  can  cite  only  the  celebrated  experi- 
ment of  Schiff  which  has  not  been  repeated :  he 
made  a  complete  section,  except  the  posterior  col- 
umns of  the  dorsal  cord  of  a  rabbit.  The  animal 
preserved  touch  sensation  very  distinctly  and  com- 
pletely lost  sensations  of  heat  and  pain. 

In  i8q4  Holzinger'"^  undertook  the  following 
experiment  in  the  clinical  laboratory  of  Bechterew 
of  St.  Petersburg.    He  cut  the  dorsal  cord  of  dogs  (  at 

^^Marinesco.  Les  polynevr.  en  rapport  avec  la  th.  des 
neur.  Soc.  de  Biol.,  30  nov.  1895.  Voir  aussi  Presse  med. 
28  dec.  1895  et  Rapport  au  Congres  de  Moscou  sur  I'histo- 
pathol.  de  la  cell,  nerv.,  aout  1897  (Revue  neurol.  1896,  p. 
54  et  70;  1897,  p.  523)  :  "Par  consequent,  conclue-t-il,  il 
n'existe  pas  de  nevrites  sans  reaction  des  cellules  des  nerfs 
atteints." 

'"Hedon.  Precis,  de  physiol.  1896.  Voir  dans  ce  livre 
(p.  474)   les  fig.  de  Goldscheider. 

''"En  un  mot,  on  pent  dire  que  I'alteration  des  cornes 
posterieures  a  pour  traduction  symptomatique  le  syndrom^ 
sur  lequel  je  me  suis  longuement  etendu."  Leg.  de  clin. 
med.,  1^^  serie,  p.  243. 

■^■^Bechterew.  Die  sens.  Bahnen  in  Riickenm.  NfuroL 
Centralbl.  1894,  p.  647. 


46  2'he  Diagnosis  of 

the  level  of  the  3rd  and  4th  pairs  of  nerves)  and 
noted:  ist.  For  sensation  to  pain  (A)  hypaes- 
thesia,  transitory  (some  days)  bilateral  on  section 
of  the  lateral  half  of  the  cord;  (B)  nothing,  on  si- 
multaneous section  of  the  posterior  columns,  of  the 
grey  matter  and  of  the  anterior  columns,  and  of  the 
anterior  part  of  the  lateral  columns  with  a  part  of 
the  anterior  horns;  (C)  analgesia  of  all  the  body 
below  level  of  lesion  by  the  section  of  the  two  lateral 
columns  or  by  section  of  the  posterior  half  of  the 
cord ;  only  in  this  latter  case  the  section  must  be 
a  little  before  (anterior  to)  the  pyramidal  tracts; 
2nd.  For  tactile  and  muscular  sensations,  anaes- 
thesia when  the  posterior  columns  are  destroyed 
(and  then  also  ataxia).  Some  analogous  results  con- 
firmative of  the  same  conclusions  appear  to  have  been 
obtained  by  Miinzer  and  Wiener.'^ 

From  these  physiological  and  especially  these 
clinical  reports  the  probable  path  in  the  cord  of  the 
fibres  conducting  pain  and  temperature^'^  may  be 
deduced. 

All  conducting  fibres  enter  by  the  posterior  root 
and  penetrate  the  posterior  horns  of  the  same  side 
at  once :  whence  we  have  thermic  and  pain  anaes- 
thesia in  certain  cases  of  a  lesion  limited  to  the  pos- 
terior horns;  analgesia  of  the  same  side  as  the  le- 
sion.^^     In  these  cases  the  analgesia  and  thermo- 

'^MiiNZER  et  Wiener.  Sur  la  destr.  isolee  de  la  subst. 
grise  medull.  Arch.  f.  experim.  Pathol,  u.  Pharmak.,  t. 
XXXV,  p.  113.  et  Revue  neurol.  1895,  p.  586. 

^°Voir  notamment  sur  ce  point  le  travail  deja  cite  de 
Max  Laehr  (1896)  et  celui  de  Schlesinger.  Localisat.  d. 
Schmerz  u.  Temperatursinnsbahnen  in  Riickenm.  Wien. 
physiol.    Club  26  mars,  Neurol.  Centralbl.  1895,  p.  751. 

^^Tel  est  le  cas  presente  (avec  autopsie)  par  Dejerine  et 
Sottas  a  la  Societe  de  Biologie  le  23  juillet  1892  (p.  716  des 

c.  r:). 


Diseases  of  the  Cord.  47 

anaesthesia  are  segmental,  each  segment  of  the  Umb 
having  its  special  medullary  center.^- 

Then  these  conducting  fibres  pass  to  :he  opposite 
side  (by  a  commissure)  :  whence  we  have  crossed 
analgesia  when  the  lesion  is  above  the  level  of  the 
center  of  the  region  affected  (the  case  in  Brown- 
Sequard  syndrome).  This  intra-crossing  does  not 
seem  to  take  place  at  the  same  height  for  the  dif- 
ferent fibres,  thermic  and  algesic  of  the  same  re- 
gion; for,  in  a  lesion  limited  to  the  posterior  horns, 
the  two  periplieral  zones  of  anaesthesia  are  not 
necessarily  superimposed.  After  their  intra-cross- 
ing. these  conducting  fibres  pass  into  the  grey  mat- 
ter and  very  probably  pass  at  once  into  the  sensory 
bundles  of  the  anterior  lateral  columns  (notably  mto 
Gower's  bundle). 

As  to  tactile  and  muscular  impressions,  they  are 
not  obliged  to  pass  by  the  relay  neurone  (posterior 
horn)  of  their  region.  When  this  neurone  is  de- 
stroyed they  continue  either  by  the  relay  neurones 
of  a  higher  level  or  by  the  posterior  white  substance 
alone  and  thus  reach  the  brain ;  whence  we  have  the 
so-called  syringo-myelic  dissociation  of  sensation  in  a 
part  of  a  limb  of  the  same  side  as  the  lesion  when  the 
lesion  is  located  in  the  corresponding  region  of  the 
posterior  horn. 

Above  this  relay  neurone  thermic  and  pain  im- 
pressions continue  by  the  grey  substance  and  the 
lateral  columns,  while  tactile  impressions  follow 
another  path  (posterior  columns).  From  this  one 
can  understand  that  a  lesion  limited  to  this  level  can 
produce  so-called  syringo-myelic  dissociation  of  the 
opposite  side  as  compared  with  the  lesion  if  located 

^"Voir  nos  Leg.  sur  les  Sympt.  medull.  a  distrib.  segment, 
publiees  par  mon  chef  de  clin.  le  D^  Gibert  dans  le  Nouveaii 
Monti),  medical  (1899). 


48  The  Diagnosis  of 

at  one  pointy  and  inverse  or  complementary  (tabe- 
tic) dissociation,®^  if  seated  at  another  point. 

Then,  to  resume,  from  pathological  physiology 
it  is  perceived  that  the  dissociation  called  syringo- 
myelic is  not  exactly  the  syndrome  of  the  posterior 
homs/^  but  often  the  syndrome  of  the  second  sen- 
sory neurone,  {the  first  neurone  of  the  relay ),^ the 
cellular  bodies  of  which  are 'in  the  posterior  hornSy 
and  zvhose  cylinder  axis  prolongations  are  in  tJie 
lateral  column  and  especially  Gozve/s  bundle  of  the 
opposite  side;  that  is  to  say,  that  the  dissociation  is 
on  the  same  side  as  the, lesion  when  this  attacks  the 
cellular  bodies  of  this  neurone  and  that  the  dissocia- 
tion is  on  the  side  opposite  the  lesion  when  this  in- 
volves the  prolongations  of  this  same  neurone.®^ 

D.  To  make  the  differential  diagnosis  of  this 
svndrome  it  is  sufhcient,  as  soon  as  the  dissociation 
is  established,  to  discuss  its  origin ;  hysterical,  neu- 
ritic,  or  medullary. 

In  hysteria  the  distribution  may  be  segmental ; 
but  there  are  other  symptoms  which  permit  a  diag- 
nosis of  the  neurosis.  It  becomes  more  difficult 
wlien  there  is  a  hystero-organic  association.     Sug- 

*^La  dissociation  inverse  ou  complementaire  est  constit- 
uee  par  I'anasthesie  tactile  et  mu^culaire  avec  conservation  et 
souvent  exaltation  de  la  sensibilite  a  la  temperature  et  a  la 
douleur. 

^*Pour  Marinesco  (Soc.  med.  des  hop.  6  mars  1896),  la 
dissociation  syringomyelique  est  due  a  I'interruption  du  con- 
tact utile  entre  les  collaterales  et  certains  neurones  de  la 
corne  posterieure ;  ce  phenomene  d'addition  et  de  renforce- 
ment  n'ayant  plus  lieu  quand  la  corne  posterieure  est  de- 
truite. 

®^Au  moment  de  mettre  sous  presse,  nous  recevons  un 
travail  de  van  Gehucten  sur  "la  dissociation  syringom- 
yelique de  la  sensibilite  dans  les  compressions  et  les  trau- 
matismes  de  la  moelle  epiniere,  et  son  explication  physiol- 
ogique."   {Sem.   med.   1899,  no  15,  p.   113). 


Diseases  of  the  Cord.  49 

gestion  here  seems  to  be  the  only  absolute  means  of 
resolvmg  the  question. 

As  to  the  peripheral  origin  I  believe  this  rare 
without  medullary  involvement.  On  the  other  hand 
the  dissociation  is  then  always  distributed  according 
to  the  nerve  territories  and  not  in  segments  ;  and  there 
are  all  the  other  ordinary  symptoms  of  neuritis. 

E.  It  is  now  time  to  consider  that  sudorific  and 
vaso-motor  disturbances  make  a  part  of  the  syn- 
drome of  the  posterior  horns. 

I  will  devote  to  them  only  an  appendix  to  the 
general  chapter  as  their  physiological  and  semei- 
ological  history  are  not  complete. 

In  a  patient  whom  I  studied  in  1889  there  were 
more  exaggerated  sweats  and  hyper-thermia  on  the 
same  side  as  the  thermo-anaesthesia  and  the  anal- 
gesia. I  have  collected  29  cases,  borrowed  from 
various  authors,^^  in  which  there  was  with  the  dis- 
sociation of  sensibility  on  one  part,  sudorific  or  vaso- 
motor troubles  on  the  other. 

From  this  frequent  association  of  the  two  classes 
of  phenomena  we  have  already  inferred  that  prob- 
ably the  lesions  corresponding  to  the  symptoms  have 
the  same  location  or  both  locations  are  near. 

The  physiologists  do  not  appear  to  know  any- 
thing of  this  location  of  the  medullary  vaso-motor 
center  (or  of  the  great  sympathetic). 

Some  make  the  anterior  columns  intervene 
(Brown-Sequard,  Schiff)  or  the  column  of  Clarke 
(Jacubowitz,  Gaskell),  but  without  proving  their 
convictions,^^ 

^^Strumpell,  FiiRSTNER  et  Zacher,  Glaser,  Remak, 
Schultze:  Will^  Gull^  Lockart-Clarke^  et  Hughlings- 
Jackson,  Westphal,  Krauss,  Oppenheim,  Freund,  Roth, 
MoRVAN,  Proust,   Dejerine,  Rumpf,   Moutard-Martin. 

®^Voir  les  art.  Vasomoteurs  de  Nuel  et  Sympathique  de 
Francois  Franck  in  Diet,  encyclop.  des  sc.  med. 

4 


50  The  Diagnosis  of 

.  The  hesitation  of  the  physiologists  is  still  greater 
for  the  localization  of  the  medullary  center  of  the 
sudorific  nerves. ^^ 

In  the  clinic,  Bouverat  showed  hyperidrosis  in 
various  cord  diseases,  but  without  saying  anything 
as  to  the  location  of  the  lesion.  In  1882  Pierret^® 
established  much  more,  and  by  applying  the  an- 
atomo-clinical  method  to  the  study  of  the  vaso- 
motor troubles  of  tabes  he  places  the  lesion  in  the 
intermedio-lateral  tract  of  Clarke. 

This  is  where  we  were  in  my  lessons  in  1889. 

A  little  later  the  observations  of  the  Saltpetriere 
on  syringo-myelic  dissociation  in  hysteria  appeared, 
and  most  remarkable  the  patient  in  whom  Charcot 
demonstrated  this  neurosic  dissociation  was  studied 
by  Gilles  de  la  Tourette*^^  from  the  point  of  view  of 
the  trophic,  vaso-motor  and  oedematous  troubles. 
Among  these  hysterics  who  "simulate  syringo-my- 
elic dissociation  we  find  swollen,  oedematous,  cold, 
cyanosed  hands  which  singularly  resemble  the  "suc- 
culent hand,"  which  Marinesco  describes  as  in  the 
true  syringo-myelics. 

Again  hysteria  has  not  so  gross  a  physiology 
and  associates  in  its  manifestations,  symptoms 
which  often  belong  to  organic  lesions :  so-called 
syringo-myelic  dissociation  and  trophic  and  vaso- 
motor troubles. 

In    1897   Marinesco®^  took   up  the   question  of 

*^Voir  Francois  Fr.\nck,  art.  Sueur  in  Diet,  encycl.  des 
sc.  med. 

^TiERRET.  Acad,  des  sc.  1882,  et  Putnam.  Th.  de  Paris, 
1882. 

■'•"Gilles  de  la  Tourette  et  Dutil.  Contrib.  a  I'et.  des 
tr.  troph.  dans  I'hyst.  Atr.  muse,  et  ded.  Nouv.  Iconogr.  de 
la  Salpetr.  1889,  p.  251. 

.^^Marinesco.  De  la  main  succulente.  Nouv.  Iconogr.  de 
la  Salpetr.  1897,  p,  84  et  202.  - 


Diseases  of  the  Co?'d.  5 1 

vaso-motor  troiiljles  in  syringo-myelia  apropos  to 
this  oedematous  hand  which  with  P.  Marie  he  called 
the  ''succulent"  hand. 

He  recalled  first  many  cases  which  had  never 
been  collected ;  theii  he  added  more  recent  cases : 
those  of  Massius  (1890),  Hoffman,  Colemann  and 
O'CarroU  (1893),  Dayot  and  Rennes  (Louazelle 
1890),  with  four  personal  observations.  (Clinic  of 
P.  Marie  and  of  Raymond). 

He  declares  Pierret's  opinion  as  to  the  location 
of  the  medullary  center  of  the  vaso-motor  nerves 
not  admissible,  and  accepts  rather  that  of  Remake- 
according  to  which  this  center  is  in  the  posterior 
grey  horns ;  each  segment  of  the  cord  containing  its 
sensory  and  vaso-motor  centers  for  the  correspond- 
ing limb. 

In  fact,  certain  anatomists®^  admit  today  that  the 
motor  influence  leaves  the  cord  by  the  posterior 
roots  and  goes  from  there  by  the  rami  communi- 
cantes  to  the  sympathetic  ganglions. 

It  is  permissible  to  think  that  these  fibres  which 
come  from  the  posterior  roots  of  the  cord,  arise  in 
the  posterior  horns  of  the  grey  substance  or  in 
neighboring  parts  (Lenhossek  and  Cajal  make  them 
come  from  the  base  of  the  anterior  horns  "also  from 
w^ithin  and  near  the  canal  as  well  as  from  outside  ) ." 

Despite  the  obscurity  which  still  persists  on  this 
question  I  believe  we  may  conclude  clinically  that 
the  dissociation  of  sensation  callled  syringo-myelic 
is  the  syndrome  of  the  posterior  horns  of  the  cord 
and  that  the  vaso-motor  and     sudorific     troubles 

^^Remak.  Berl.  klin.  Wochenschr.  1889,  no  3  (cit.  Mari- 
nesco) . 

^^Voir  Van  Gehuchten.  Ahat.  du  syst.  nerv.  de  Thom., 
26  edit.  1897,  p.  895,  et  Poirier.  Traite  d'anat  hum.  1884, 
t.  Ill,  p.  215. 


52  The  Diagnosis  of 

(when  they  are  of  medullary  origin)  are  the  syn- 
drome of  the  posterior  and  central  grey  matter 
(base  of  the  anterior  horns). 

7.  The  Associated  Syndrome  of  the  Anterior 
Horns  and  of  the  Centro-posterior  Grey 
Matter  (the  Syndrome  of  the  entire  Grey 
Matter):  Muscnlar  Atrophy,  Dissocia- 
tion of  Sensation  called  Syringo-myelic 
and  Yaso-motor  Troubles. 

This  syndrome,  the  anatomo-clinical  and  patho- 
logical physiology  of  which  is  explicitly  contained 
in  paragraphs  4  and  6,  is  especially  found  in  two 
classes  of  cases :  syringo-myelias  with  amyotrophies 
and  amyotrophies  with  vaso-motor  troubles. 

1.  Syringo-myelia  shows  itself  by  amyotrophy 
and  dissociation  of  sensation  at  a  time  when  the 
lesion  involves  simultaneously  the  anterior  and  pos- 
terior portions  of  the  grey  matter :  in  these  cases  the 
amyotrophy  has  the  characters  which  we  have  as- 
signed to  amyotrophies  of  medullary  origin. 

Marinesco  has  insisted  on  the  frequency  of  the 
preacher's  hand  in  these  cases  as  described  by  Char- 
cot and  Joffroy  in  hypertrophic  cervical  pachymen- 
ingitis and  characterized  by  the  predominance  of 
atrophy  in  the  regions  of  the  ulnar  and  median 
nerves ;  further  in  these  same  patients  the  muscular 
atrophy  (of  the  Aran-Duchenne  type)  always  has  a 
very  segmental  distribution.^* 

2.  In  amyotrophies  there  is  often  noted  hyper- 
thermia, the  violet  or  livid  hand  (Vulpian).  I  have 
noted  hyperthermia,  and  local  sweats.     Frommann, 

.®*Voir  le  fait  d'amyotr,  en  frant  recerru  publie  par  Crocq 
(Journ.  de  neurol.  de  Bruxelles  1899). 


Diseases  of  the  Cord.  53 

Friedreich,  Wunder,  Leich,  Leyden  have  also  de- 
scribed exaggerated  sweats  in  certain  amyotrophic 
cases. '^^ 

It  seems  useless  to  insist  further  on  this  point. 

8.    The  Syndrome  of  the  Lateral  Half  of  the 
Cord:  Crossed  Hemiparaplegia. 

A.  In  1849,  Brown-Sequard^^  described  the 
symptoms  observed  after  a  lesion  of  the  half  of 
the  cord :  there  is  a  crossed  hemiparaplegia  or 
Brown-Sequard  syndrome,  characterized  by  motor 
paralysis  and  hyperaesthesia  of  the  same  side  as  the 
lesion,  and  anaesthesia  of  the  opposite  side. 

More  exactly  we  find:  ist.  On  the  side  corres- 
ponding to  the  lesion  a  motor  paralysis,  normal  or 
exaggeration  of  the  various  sensations,  a  zone  of 
anaesthesia  in  the  upper  portion  of  the  part  near  the 
lesion  and  often  a  zone  of  hyperaesthesia  above,  hy- 
perthermia and  paralysis  of  the  sympaihetic,  ar- 
thropathies, muscular  atrophy;  2nd.  On  the  side 
opposite  the  lesion  there  is  preservation  of  voluntary 
movement  and  of  the  muscular  sense,  anaesthesia 
in  all  forms,  sometimes  a  zone  of  hyperaesthesia 
above  the  level  of  the  lesion  (the  crossed  sensory 
troubles  rising  not  quite  so  high  as  those  on  the  side 
of  the  lesion). 

All  authors  have  confirmed  this  clinical  descrip- 
tion.    It  has  been  completed  by  showing  that  often 

®^Voir  notre  Traits  des  mal.  du  syst.,  nerv.  4©  ed  (en  col- 
lab,  avec  Rauzier),  1894,  t.  I,  p.  610. 

^*Les  divers  travaux  de  Brown-Sequard  sur  I'anesthesie 
spinale  croisee  sont  echelonnes  depuis  sa  these  en  1846 
jusqu'en  1894.  Les  memoires  les  plus  importants  sont  ceux 
de  1849  a  la  Societe  de  Biolo^ie,  de  1863  dans  le  Journal  de 
la  physiologic,  de  1868  et  1894  dans  les  Archives  de  physi- 
ologic. 


54  The  Diagnosis  of 

the  anaesthesia  is  dissociated  (of  the  syringo-myelic 
type)  ;  the  same  had  been  noted  in  certain  observa- 
tions collected  at  first  by  Brown-Sequard,  especially 
those  of  Vigues.  Sometimes  there  is  only  thermo- 
anaesthesia. 

This  unilateral  dissociation  is  habitually  crossed 
in  relation  to  the  lesions.  More  rarely  it  is  direct, 
especially  in  the  case  of  Dejerine  and  Sotttas.^^  In 
this  latter  case,  the  motor  paralysis  which  is  always 
direct  (as  in  the  classic  cases)  is  on  the  same  side 
as  the  anaesthesia ;  then  we  do  not  have  the  Brown- 
Sequard  syndrome  proper.  However,  these  are 
cases  which  we  ought  not  to  overlook  when  study- 
ing the  syndrome  of  the  lateral  half  of  the  cord.  We 
will  take  them  up  again  apropos  to  the  pathological 
physiology. 

The  Brown-Sequard  syndrome  is  clear  and  com- 
plete (as  we  shall  describe  it)  when  the  lesion  is 
exactly  limited  to  the  lateral  half  of  the  cord.  We 
observe  it  in  an  attenuated  and  incomplete  form 
when  the  lesion,  more  extended  is  more  marked  in 
one  half  than  in  the  other.  In  this  case  the  motor 
paralysis  and  anaesthesia  are  bilateral ;  only  the 
paralysis  is  more  marked  on  the  side  of  the  lesion 
and  the  anaesthesia  (complete  or  dissociated)  is 
more  marked  on  the  side  opposite  to  the  lesion. 

Complete  or  incomplete,  the  Brown-Sequard 
syndrome  is  always  a  very  good  sign  of  the  medul- 
lary location  of  the  lesion.  Outside  of  the  cord  two 
different  lesions  are  necessary  to  produce  this. 

B.  The  diseases  capable  of  producing  the 
Brozvn-Sequard  syndrome  (complete  or  incomplete) 
are  numerous.    Any  medullary  lesion  will  produce 


®^Dejerine  et  Sottas,  Soc.  de  Biol,  23  juillet  1892.   Obs. 
deja  citee. 


Diseases  of  the  Cord.  55 

it  with  the  single  condition  that  it  involve  exclu- 
sively a  half  of  the  cord  or  only  one  half  of  the  cord 
more  than  the  other. 

We  will  note:  traumatic  lesions  (fracture,  lux- 
ation, hemorrhages,  .bullet  wounds),  vertebral  ar- 
thritis, spinal  meningitis,  hemorrhagic  foci,  diffuse 
myelitis,  syringo-myelia,  tumors,  various  syphilitic 
localizations,^'^  (syphilomas,  myelitis,  gummatous 
meningitis),  etc. 

C.  The  pathological  physiology  of  this  symp- 
tom still  remains  difficult  and  is  much  discussed 
despite  the  works  which  it  has  provoked  for  a  half 
century. 

It  concerns  us  to  study  in  extent  only  crossed 
anaesthesia.  For,  for  the  direct  paralysis  no  one 
disputes  the  pathogeny  which  is  very  simple,  the 
lesion  involving  the  medullary  motor  fibres  which 
have  already  crossed  at  the  pyramids. 

To  explain  the  crossed  anaesthesia,  Brown-Se- 
quard,  in  his  first  works,  admitted  that  the  medul- 
lary sensory  fibres  cross  in  the  cord  at  every  level  of 
the  cord  from  their  entrance  into  the  cord  by  the 
posterior  roots.  This  explains  the  crossed  anaes- 
thesia ;  the  hyperaesthesia  above  the  level  of  the  le- 
sion is  due  to  irritation  of  the  surrounding  part,  as 
is  also  the  hyperaesthesia  of  the  same  side  as  the 
lesion ;  the  direct  zone  of  anaesthesia  at  the  level  of 
the  lesion  is  due  to  a  change  in  the  nerves  at  their 
entrance  into  the  cord  before  their  crossing. 

Physiologically^^   Brown-Sequard  shows  anaes- 

°*Voir  Lamy.  La  meningomyel.  syphil.  Paris.  1893. — 
Sottas.  Contrib.  a  I'etude  anat.,  clin.  des  paral.  spin, 
syphil  Paris  1894. — Gilles  de  la  Tourette.  Formes  clin. 
et  trait._  des  myel.  syphil.    Les  Actualites  medic.  1899. 

'^Voir  pour  tout  ce  paragr.  Dejerine  et  Thomas.  ;Un 
cas  d'hemiparapl.  avec  anesth.  croisee.  Syndr  de  Brown- 
Sequard  suivi  d'aut.     Arch,  de  physiol.  1888,  p.  594. 


56  The  Diagnosis  of 

thesia  of  the  hinder  Hmbs  after  a  double  hemi-sec- 
tion,  one  in  the  dorsal  region,  and  the  other  in  the 
cervical  region  or  after  a  longitudinal  section  sepa- 
rating into  two  lateral  halves  the  lumbar  enlarge- 
ment of  the  cord,  (Galien's  experiment,  remade  by 
Fodera^"^'  \%2;iy).  The  same  experiment  in  the  cervi- 
cal region  produced  complete  anaesthesia  of  bath 
anterior  limbs  with  preservation  of  sensation  in  the 
hinder  limbs. 

To  this  theory  the  physiologists  have  made  and 
still  make  numerous  objections  and  Vulpian  ^^^  who 
was  one  of  the  first  adversaries  of  Brown -Sequard's 
ideas,  admitted  that  the  hyperaesthesia  (in  a  uni- 
lateral lesion  of  the  cord)  above  and  below  the  level 
of  the  lesion  is  produced  by  the  local  excitation  and 
that  the  crossed  anaesthesia  is  due  to  a  depression 
correlative  to  the  excitability  of  the  analogous  parts 
of  the  cord ;  the  physiological  balancing  of  the  two 
halves  of  the  cord. 

These  are  some  of  the  arguments  of  the  adver- 
saries to  the  theory  of  the  intra-medullary  intra- 
crossing  of  the  sensory  tracts.^^^ 

1.  Among  animals  after  unilateral  section  of  the 
cord,  if  hyperaesthesia  is  the  rule  (Fodera,  Vul- 
pian) crossed  anaesthesia  is  on  the  contrary  "a  phe- 
nomenon of  very  variable  intensity  in  different  ani- 
mals and  is  not  generally  absolute." 

2.  Unilateral  section  has  moreover  less  influ- 
ence on  the  hinder  limbs  the  further  it  is  from  the 
lumbar  cord.  (Vulpian). 

3.  Tn  the  experiment  of  Van  Deen   (unilateral 


1001 


ToDERA  (1823)  et  ScHOPS  (1827)  avaient  entrevu  le 
syndrome  de  Brown- Sequard. 

"^Vulpian.  Art.  Moelle  epin.  (Physiol.)  in  Diet,  en- 
cycl.  des  sc.  med.  1874,  2^  serie,  t.  VIII, 

^°"Voir  Tart,  cite  de  Dejerine  et  Thomas. 


Diseases  of  the  Cord.  57 

section  toward  the  posterior  portion  of  the  dorsal  cord 
and  a  complementary  unilateral  section  in  the  cervical 
region)  both  hinder  limbs  retained  sensation  even 
if  one  unilateral  section  extended  over  the  median 
line  (dog,  A'ulpian ;  rabbit,  Schiit). 

4.  The  longitudinal  section  of  the  lumbar  en- 
largement in  the  median  line  produces  only  a  simple 
diminution  of  sensation  (Ore). 

5.  ]\lore  recently  S.  ]\Iott^""  reached  analogous 
conclusions  for  the  nionke}" :  painful  and  thermic  sen- 
sations can  be  conducted  by  both  sides  of  the  cord, 
tut  touch  sensations  and  those  of  pressure  are  prin- 
cipally conducted  by  the  same  side  :  there  will  be  a 
considerable  retardation  in  the  transmission  of  the 
impressions  received  by  the  paralyzed  side  and  some 
errors  in  localization.  In  resume,  in  the  monkey  an- 
aesthesia is  principally  direct. 

6.  Gotch  and  Horsley^"^  have  made  researches 
as  to  the  electric  modifications  which  are  produced 
in  the  various  bundles  of  the  dorsal  cord  when  elec- 
tric excitation  is  applied  to  the  sciatic  nerve  or  to  the 
posterior  roots  of  the  lumbar  plexus.  In  a  way  they 
measure  by  the  intensity  of  this  electric  modification 
the  quantity  of  nerve  energy  which  passes  into  these 
bundles  of  the  cord  when  the  nerve  in  question  is 
excited. 

In  the  cat  and  monkey,  the  current  in  the  cord  is 
principally  unilateral  and  of  the  same  side  in  the 
proportion  of  80  per  cent  and  principally  by  the  pos- 
terior column. ^'^"' 

^°^]\IoTT.  Res.  of  hemis.  of  the  spin.  Cord  in  ^lonkeys, 
Philos.  Transact.  1891.  Cit.  Dejerine  et  Thomas. — ^\'^oir 
aussi  la  discussion  de  ces  exper.  par  Marinesco  in  Scm. 
mid.  1896.  p.  263. 

^"^GoTCH  et  HoRSLEY.  On  the  mammalian  nerv.  syst.,  its 
Funct.  and  their  Localis.  determ.  by  an  electr.  ^Nleth.  Phil- 
osoph.   Transact.   iSqi.     Cit.  Dejerine  et  Thomas. 


58  The  Diagnosis  of 

Many  months  after  the  hemi-section  of  the  cord 
the  electric  modification  above  the  hemi-section  is 
three  times  less  strong  than  if  the  excitation  is  applied 
to  the  opposite  side. 

In  resume  Dejerine  and  Thomas  grouping  the 
facts  of  experimental  physiology^"^  conclude  that 
the  intra-crossing  of  the  sensory  tracts  is  not  oem- 
plete  in  the  cord ;  undoubtedly  a  partial  intra-cross- 
ing occurs ;  that  in  certain  animals  the  intra-crossed 
fibres  are  more  numerous  than  the  direct;  in  other 
animals  (the  monkey  and  the  cat)  the  contrary  is  a 
fact. 

Impressed  by  all  these  arguments  Brown-Se- 
quard^^^  himself  toward  the  close  of  his  life  aban- 
doned his  first  theory.  He  recalls  that  a  puncture  of 
the  posterior  cord  of  one  side  can  produce  the  syn- 
drome; that  after  first  a  imilateral  section  in  the 
cervical  cord  with  consecutive  hemianaesthesia,  if  a 
second  dorsal  unilateral  section  were  made  hyper- 
aesthesia  replaces  the  hemianaesthesia  and  vice 
-versa ;  that  hemianaesthesia  consecutive  to  a  uni- 
lateral section  of  the  cord  may  disappear  after  a 
stretching  of  the  sciatic  nerve  on  the  side  of  the 
anaesthesia.  And  then  according  to  him  the  anaes- 
thesia in  his  syndrome  becomes  a  matter  of  inhi- 
bition and  the  hyperaesthesia  a  matter  of  over-ac- 
tivity. 

^°^I1  seriat  utile  d'etablir  que,  chez  ces  animaux.  I'excita- 
tion  electrique  est  comparable,  pour  les  voies  de  conduction 
intramedullaire,  a  I'excitation  venue  des  organes  sensitifs 
peripheriques. 

^°®Voir  aussi  Bottazzi.  Sur  Themis,  de  la  moelle  epin. 
Riv.  sperim.  di  fren.  1896,  t.  XXI  ttRevue  neurol,  1896,  p. 
Z72. 

"^Brown-SEQUARD.  Rem.  a  propos.  des  rech.  du  Dr  Mott 
sur  les  effets  de  la  sect,  d'une  moitie  later,  de  la  moelle  epin. 
Arch,  de  physiol.  1894. 


Diseases  of  the  Cord.  59 

This  opinion  so  plainly  settled  has  separated  the 
clinicians  from  the  physiologists.  And  so  Bris- 
saud^^^  has  continued  to  defend  and  to  represent  in 
a  scheme  the  intra-medullary  dissociation  of  the  sen- 
sory tracts,  Raymond^^^  appeared  disposed  to  take 
up  Brown-Sequard's  last  opinion,  and  Dejerine  and 
Thomas,  recognizing  that  it  is  formulated  in  "very 
vague  terms'^  are  tempted  however  ''to  take  into 
consideration  the  last  opinion  of  Brown-Sequard, 
already  moreover  sustained  by  Vulpian."  And  they 
add  "Whatever  it  is,  it  is  impossible  to  put  Brown- 
Sequard's  theory  on  a  solid  basis,  especially  vv^hen 
theories^^"  are  preferred  to  facts. "^^^ 

It  seems  to  me  that  the  question  can  be  presented 
in  a  less  discouraging  manner.  Without  lessening  the 
value  of  the  conclusions  accumulated  by  experi- 
mental physiology  it  may  be  remarked  that  all  these 
experiments  establish  a  single  thing:  the  mode  of 
intra-medullary  transmission  of  sensory  impressions 
in  animals. 

But  in  man  things  may  take  place  differently: 

^"^Brissaud.  Hemiparapl.  spin  avec  hemianesth.  croisee, 
syndr.  de  Brown-Sequard  in  Leg.  sur  les  mal,  nerv.  1895, 
p.  246,  (leg  du  15  dec.  1893). — Le  double  syndr.  de  Brown- 
Sequard  dans  la  syph.  spin  Pr ogres  med.  1897  nos  29  et  51. 
Voir  aussi  Londe.  Double  syndr.  de  Brown-Sequard  dans 
le  mal  de  Pott.  Revue  neurol.  1898,  p.  356. 

"^Raymond.  Synd.  de  Brown  Sequard  d'orig.  probabl. 
syringomyel.  (Leg.  du  28  juin  1895)  in  Clin,  des  mal.  du 
syst.  nerv.  1896,  t.  I,  p.  315  et  sur  un  cas  d'hemis,  traumat. 
de  la  moelle  (syndr.  de  Brown-Sequard).  Lee.  du  20  noy. 
1896  in  Clin,  des  mal.  du  syst.  nerv.  1898,  t.  Ill,  p.  508. 

""Le  schema  qui  est  un  moyen  indispensable  d'enseigne- 
ment  ne  me  parait  pas  si  dangereux  tant  qu'il  reste  ce  qu'il 
devrait  toujours  etre:  un  resume  et  une  expression  syn- 
thetique,  toujours  revisables,  des  faits  observes. 

"^Voir  aussi  les  idees  de  Dejerine  dans  la  these  (Paris 
1899)  de  Zong  sur  les  voies  centrales  de  la  sensibilite 
generale. 


6o  The  Diagnosis  of 

the  specialization  of  functions  in  the  nervous  system 
is  always  increasing  in  proportion  as  you  go  up  the 
animal  scale.  If  this  principle,  which  I  believe  indis- 
putable, is  admitted;  it  must  be  recognized  that  the 
anato  mo -clinic  at  method  is  the  only  one  which  can 
decide  whether  one  should  or  should  not  apply  the 
conclusions  of  experimental  physiology  to  man." 

That  is  to  say  that  the  clinical  facts  if  they  are 
pretty  numerous  and  well  observed,  have  their  value 
by  the  side  of  and  in  the  face  of  physiological  facts. 

To  24  observations  collected  by  Brown-Sequard 
in  his  memoir  of  1863  a  great  many  new  facts  have 
been  added,  many  of  which  are  recent  and  with 
autopsy  and  all  establish  the  reality  of  Brown-Se- 
quard's  syndrome ;  that  is  to  say  prove  that  in  a  uni- 
lateral lesion  of  the  cord  there  is  a  direct  motor 
paralysis  and  crossed  anaesthesia. 

Then  in  conclusion,  it  seems  to  me  irrefutable 
that  things  take  place  from,  this  point  of  viezv  dif- 
ferently in  man  and  animals. 

If  Brown-Sequard's  syndrome  is  admitted  as  a 
clinical  law  (and  this  appears  certain)  the  intra- 
medullary crossing  of  the  sensory  fibres  in  man 
must  be  admitted.  We  come  back  then  to  Brown- 
Sequard's  first  theory  which  alone  explains  or  at 
least  expresses  the  clinical  fact. 

Anaesthesia  is  direct  in  a  limited  region  where 
the  sensory  fibres  are  injured  at  their  entrance  into 
the  cord  before  their  intra-crossing ;  it  is,  on  the 
contrary,  crossed  in  the  more  extended  region  where 
the  sensory  fibres  are  injured  in  their  intra-crossing. 
Hyperaesthesia  develops  by  irritation  of  the  neigh- 
boring parts  in  limited  regions  where  the  sensory 
fibres  pass  into  the  cord  on  the  side  of  the  lesion. 

By  combining  this  with  what  has  already  been 
said  in  the  pathological  physiology  of  the  dissocia- 


Diseases  of  the  Cord.  6i 

tion  called  syringo-niyelic,  it  can  be  understood  how 
crossed  dissociation  occurs  in  certain  Brown-Se- 
quard  cases. 

D.  The  differential  diagnosis  is  short.  The 
Bro.wn-Sequard  syndrome  complete  or  incomplete  is 
in  a  word  characteristic  and  corresponds  always  to 
the  medullary  site  of  the  lesion. 

A  single  case  should  be  distinguished,  that  of  a 
double  lesion.  The  syndrome  is  pathognomonic  of 
a  medullary  origin  only  when  the  direct  paralysis 
and  crossed  anaesthesia  can  be  explained  by  a  single 
lesion. 

If  there  is  a  double  lesion  (extra-medullary, 
root,  or  neuritic)  the  distribution  of  the  affection 
will  generally  follow  the  nerve  territories  instead  ot 
being  segmental ;  further  the  two  lesions  will  gen- 
erally have  appeared  at  different  times  and  each 
one  will  have  its  peculiar  independent  symptoma- 
tology. 


II.    DIAGNOSIS  OF  THE  HEIGHT  OF  THE 
LOCATION  OF  MEDILLAHY  LESIONS. 

1.    Greneral  Principles  as  to  Diagnosis  of -the 
Heiglit  of  Lesions. 

In  the  preceding  chapter,  studying  the  semeiology 
of  the  various  systems  of  the  cord  we  have  en- 
deavored to  make  the  diagnosis  of  the  breadth  of 
the  location. of  the  medullary  lesion. 

It  remains  now  to  indicate  the  elements  of  a 
diagnosis  as  to  the  height  of  the  lesion. 

Being  given  a  lesion  of  the  cord,  the  following 
elements  useful  in  making  this  diagnosis  may  be 
derived : 

I  St.  The  external  signs  of  the  initial  lesion  :  frac- 
ture, luxation,  deviation,  gibbosity.  To  give  to  these 
signs  (when  one  finds  them)  their  full  semeiologicai 
value  as  to  the  medullary  location,  it  is  necessary  to 
call  attention  to  the  correspondence  between  the 
spinous  processes  (the  part  most  accessible  to  clin- 
ical exploration)  and  the  vertebral  bodies  and  in 
consequence  to  the  roots  of  the  various  spinal 
nerves. 

Here  are  the  indications  given  by  Chipault^^-  on 
the  relation  of  the  spinal  processes  to  the  origin  of 
the  spinal  roots :  'Tn  the  adult,  in  the  cervical  re- 
gion add  one  to  the  number  of  a  determined  process 
to  give  the  number  of  the  root  which  rises  at  this 

"^Chipault.  Sur  les  rapp.  des  apoph.  epin.  avec  la 
moelle,  les  rac.  medull.  et  les  men.  Th.  de  Paris  1894 — Cit. 
Raymond.    Clin,  des  mal.  du  syst.  nerv.  1896,  t.  I,  p.  275. 

62 


Diseases  of  the  Cord.  63 

level;  in  the  upper  dorsal  region,  add  two;  from  the 
6th  to  the  nth  dorsal  process  add  three;  in  the 
lower  part  from  the  nth  and  the  subjacent  inter- 
spinous  space  they  correspond  to  the  last  three  pairs 
of  lumbar  nerves,  thq  12th  dorsal  process  and  the 
subjacent  space  correspond  to  the  sacral  pairs. Z'^^" 

2.  The  motor  paralysis  and  anaesthesia  fur- 
nish valuable  information  by  their  distribution  and 
especially  by  their  upper  limit. 

When  the  lesion  affects  an  entire  section  of  the 
cord  the  paralysis  and  anaesthesia  involve  the  part 
below  the  lesion  particularly,  but  if  the  lesion  is  par- 
tial only  the  region  whose  innervation  depends  on 
the  zone  destroyed  is  affected. 

3rd.  A  more  disputable  and  today  still  more  dis- 
cussed question  is  that  of  the  semeiological  value  of 
the  state  of  the  reflexes. 

At  first  sight  the  matter  appeared  very  simple 
to  the  clinicians  who  applied  the  classic  formula  of 
the  physiologists :  the  reflex  power  of  the  cord  is 
increased  in  the  parts  separated  from  the  higher 
centers  by  a  section  of  the  cord ;  the  brain  normally 
exercises  an  inhibitory  action  over  the  reflex  power 
of  the  cord ;  when  a  section  or  a  lesion  hinders  the 
passage  of  this  inhibitory  action,  the  reflexes  are  ex- 
aggerated below  the  section  or  the  lesion.  On  the 
other  hand,  when  the  lesion  involves  a  zone  of  the 
cord  the  reflexes  which  have  their  center  exactly  in 
this  zone  will  naturally  be  lost. 

From  this  arises  this  clinical  rule,  which  was  of 

"^On  trouvera  a  la  page  657  du  Traite  d'anat.  hum.  de 
Testut.  36  edit.  1897,  t.  II,  un  tableau  complet  des  "origines 
spinales  des  nerfs  rachidiens  rapportees  aux  apophyses  epin- 
euses." 


64  The  Diag7iosis  of 

great  assistance  in  the  diagnosis  of  the  height  of  the 
medullary  lesion :  when  a  lesion  affects  a  section  of 
the  cord  the  reflexes  zvhose  centers  are  belozv  the 
lesion  are  exaggerated,  and  the  reflexes  whose  cen- 
ters are  at  the  level  of  the  lesion  are  lost.  This  is 
the  classic  law  applied  in  transverse  myelitis  and  in 
compression  of  the  cord.  *. 

But  there  are  facts  which  seem  to  weaken  this 
law.  In  1890  Bastian^^^  published  four  cases  in 
which  the  cervical  or  dorsal  cord  was  entirely  de- 
stroyed and  where  the  reflexes  were  abolished,  the 
bladder  and  rectum  alone  remaining  intact.  From 
this  the  attention  was  directed  to  the  flaccid  para- 
plegia of  certain  cases  of  transverse  myelitis  and  of 
certain  compressions  of  the  cord  and  other  cases 
have  been  published,  first  by  Bowlby,  Rooth, 
Babinski^^^  and  ourselves.^^^  Vulpian^^'  had 
mentioned  the  disappearance  of  the  reflexes  in  cer- 
tain cases  of  transverse  myelitis  where  the  lesion 
was  deep,  and  Kadner  ( 1876),  Weiss  (1878),  Kah- 
ler  and  Pick  (1880),  Schwartz  (1882),  Thorburn"« 
(1887- 1 888)  have  published  analogous  cases. 

More  recently  the  observations  of  Jackson 
(1892),  Bruns  (1893),  Gehrardt  (1894),  Hitzig 
(1894),  Egger  (1895),  Hoche  (1896),  Habel 
(1896),  and    the    important    memoirs    of    van    Ge- 


1141 


*Bastian.  Brit.  med.  Journ..  1890,  p.  480.  Anal,  in 
Rev.  des  sc.  med.,  t.  XXXVI,  p.  520 — Premiers  trav.  du 
meme  sur  ce  sujet  en  1882  et  1886. 

^^^Babinski.    Parapl.  flasque  par  compress,  de  la  moelle. 
Arch,  de  'med.  experim.  1891,  p.  228. 

^^^Mal  de  Pott  et  parapl.  flasque  anesthes.   (leg.  de  1893) 
in  Leg.  de  din.  med.  1896,  2©  serie,  p.  372. 
"'Cit.  Brissaud. 
"*Git.  Van  Gehuchten. 


Diseases  of  the  Cord.  65 

huchten,""    Marinesco^-'^   and    Brissaud^-'   have   ap- 
peared. 

From  all  these  documents  it  must  be  concluded 
that  the  ancient  classic  law  of  the  reflexes  is  no 
longer  true,  and  that  in  a  certain  number  of  cases 
there  is  an  abolition  of  reflexes  whose  medullary 
centers  are  below  the  level  of  the  lesion.  It  is  less 
easy  when  the  theory  of  these  facts  is  attempted. 

Bastian  has  taken  the  opposite  of  the  classic  the- 
ory :  in  the  normal  state  the  action  of  the  higher 
centers  is  necessary  to  the  medullary  reflex;  when 
this  dynamogenic  action  is  suppressed  by  a  section 
or  complete  lesion  all  the  reflexes  below  are  abol- 
ished; the  reflexes  are  preserved  or  exaggerated 
only  if  the  transverse  destruction  of  the  cord  is  par- 
tial. This  theory  explains  very  well  the  new  facts  of 
flaccid  paraplegia,  but  fails  by  taking  no  account  of 
spastic  paraplegia;  though  these  cases  (as  in  the 
observations  of  physiologists  in  animals)  exist  and 
perhaps  are  in  the  majority.  To  meet  Marinesco's 
opinion  Brissaud  has  shown  that  there  are  cases  of 
transverse  and  complete  lesion,  verified  by  autopsy, 
wath  preservation  or  exag8:eration  of  reflexes.  Such 
cases  are  those  of  Gehrardt,  Senator  and  those 
which  Brissaud  communicated  to  the  Congress  at 
Angers.     Then,  the  theory  of  Bastian  is  also  as  im- 

^^^Van^  Gehuchten.  Le  mecan.  des  mouv.  refl.  Un  cas 
de  compress,  de  la  moelle  dors,  avec  abolit.  des  refl.  Journ 
de  neiirol.  1897,  p.  262,  282,  302  et  322;  et  Etat  des  refl.  et 
anat.  pathol.  de  la  moelle  lombo-sacree  dans  les  cas  de  parapl. 
flasque  dus  a  ime  les.  de  la  moelle  cervico-dors.  Ibid.  5 
juin.  1898. 

^-"AIarinesco.      Sur  les  parapl.    flasques  par  compression 
de  la  moelle.     Sem.  med.  1898,  p.  150. 

^"Brissaud.  La  parapl.  flaccide  par  compress.  Revue 
neiiroi.  1898,  p.  350;  et  Congres  d' Angers,  aout  1898,  {Ibid 
p.  589). 


66  The  Diagnosis  of 

possible  to  sustain  as  the  old  classic  theory :  both  are 
too  exclusive  and  neither  explains  all  the  facts. 

Van  Gehuchten's  theory  is  derived  from  Bastian's 
only  the  Louvain  professor  adds  the  notion  of  a 
double  cortico-spinal  path  maintaining  the  medul- 
lary tonus  by  the  action  of  higher  centers :  a  direct 
inhibitory  path,  an  indirect  (by  the  medulla)  excit- 
ing :  a  lesion  of  the  pyramidal  fibres  exaggerates  the 
reflexes ;  a  complete  lesion  of  the  cord  suppresses  all 
the  reflexes.  This  theory  is  liable  to  the  same  ob- 
jections as  Bastian's. 

A  definite  theory  does  not  appear  to  have  been 
found.  However,  Brissaud  showed  in  a  great  many 
observations  of  cases  of  flaccid  paraplegia  an  altera- 
tion of  the  nerves  or  of  the  medullary  cells  below 
the  lesion,  that  is  at  the  level  of  the  paralysis. 

If  this  view  were  accepted,  the  old  classic  theory 
might  persist. 

When  the  lesion  is  cervico-dorsal  the  reflexes  of 
the  lumbar  region  will  be  exaggerated  so  long  as 
there  is  no  secondary  lesion  of  the  nerves  or  lumbar 
cells.  When  this  secondary  lesion  exists  the  re- 
flexes having  their  centers  in  this  region  will  natu- 
rally be  abolished. 

This  is  what  I  expressed  theoretically  in  1893 
when  I  said,^--  "The  gibbosity  occupying  the  cer- 
vical or  dorsal  region,  the  paraplegia  will  be  dorso- 
lumbar  in  its  aspect;"  and  by  its  secondary  lesion, 
adds  Brissaud. 

Pierret^-^  accepted  this  view  and  declared  "That 
the  lack  of  secondary  contracture  could  be  attributed 
to  a  peripheral  neuritis." 


"Leg.  citee  sur  le  mal  de  Pott  et  la  parapl.  flasque  anesth. 

194- 

^^PiERRET.     Congr 

newol.  1898,  p.  583. 


p.  394- 

'^^PiERRET.     Congres  d' Angers,  aout  1898,  p.  583.    Revue 


Diseases  of  the  Cord.  67 

Whatever  these  disputable  theories  may  be  let  us 
remember  that  the  reflexes  are  not  always  exag- 
gerated nor  preserved  below  the  lesion.  Then,  when 
they  are  exaggerated,  this  can  Ije  used  in  the  diagno- 
sis of  the  height  of  the  medullary  lesion ;  but  when 
they  are  lost  they  cannot  always  be  utilized  in  this 
direction. 

4.  These  things  said,  we  will  study  successively 
the  semeiology  of  the  conus  medullaris,  sacral,  lum- 
bar, dorsal,  brachial  and  cervical  cords. 

The  syndromes  may  be  divided  into  two  groups : 
the  syndromes  of  the  root  distribution  and  syn- 
dromes of  the  metameric  or  segmental  distribu- 
tion.^2* 

It  is  known  that  for  the  same  part  of  the  cord  the 
distribution  of  symptoms  is  not  identical  and  the 
tw^o  orders  of  symptoms  are  not  superimposed.  The 
root  distribution  is  observed  when  the  medullary  le- 
sion involves  the  zones  of  entrance  of  the  roots,  and 
the  segmental  when  the  lesion  affects  the  centers 
themselves  of  the  cord.  Moreover,  physiological 
segmentalization  can  be  naturally  observed  only  in 
the  lumbar  cord  and  above.  From  this  it  results 
that  we  will  have  only  a  single  syndrome  (radiculo- 
segmental)  for  the  conus  and  sacral  cord  while  for 
the  portions  above  we  will  separately  describe  the 
root  and  segmental  syndrome. 

^^*"Segmentaire"   veut   dire   ici   symptome   se   distribuant 
"par  segment  de  membre." 


68  The  Diagnosis  of 

2.    The    Root- Segmental    Syndrome    of  ^ the 
Conns  Mednllaris.^^' 

The  anatomists^-*^  limit  the  terminal  conus  to  the 
level  between  the  last  sacral  and  the  first  coccygeal 
pair. 

The  clinicians  include  the  last  two  (Raymond) 
or  three  (Miiller)  sacral  pairs. 

In  favor  of  this  last  limitation  ]vliiller  has  given 
arguments  derived  from  the  histological  structure: 
the  anterior  roots  there  become  scarce  and  the  pyra- 
midal tracts  disappear. 

Let  us  then  adopt  this  definition  of  the  conus : 
the  most  inferior  portion  of  the  cord^-"  from  which 
arise  the  last  three  sacral  pairs  (3rd,  4th  and  5th) 
and  the  coccygeal  nerves. 

To  philosophically  retain  the  distribution  of  the 
nerves  of  the  conus  it  is  necessary  to  place  man  on 
four  feet;  then  the  sensory  region  of  these  nerves  is 
the  most  posterior  surface  of  the  body  (sacrum,  coc- 
cyx, anus  and  perinaeum),  as  to  the  motor  distri- 

^"^Voir  nos  leg.  sur  les  paral.  nucleaires  des  nerfs  sacres  in 
Leg.  de  din.  med.  1898,  3^  serie,  p.  249;  Dufour.  Contrib. 
a  I'etude  des  nerfs  de  la  queue  de  cheval  et  du  cone  terminal. 
Th.  d  P^ris  1896;  Raymond.  Sur  les  les.  de  la  queue  de 
cheval  (14  et  21  dec.  1894)  et  hematomyelie  du  cone  terminal 
(24  mai  1895)  in  Leg.  sur  les  mal  du  syst.  nerv.  1896,  t.  I, 
p.  252  a  314;  MuLLER.  Untersuch.  lib  d.  Anat.  u  Pathol,  d. 
untersten  Riickenmarksabsch.  (Clin.  med.  du  prof.  Strum- 
pell  a  Erlangen)  D.  Zeitschr.  f.  Nervenh.,  t.  XIV.  p.  i,  (22 
dec.  1898).  Bonne  bibliogr.  p.  88  et  Schmeas  interessants. 
pi.  I  et  11. 

^^^Charpy  in  Traite  d'anat.  hum.  de  Poirier. 

^"'On  pourrait  rattacher  au  cone  medullaire  le  filum  ter- 
minal, ^lais  si,  pour  Tanatomiste,  ce  filum  represente  une 
moelle  coccygienne  ou  caudale,  plus  ou  moins  rudimentaire, 
on  pent  dire  qu'il  n'existe  pas  pour  le  clinicien;  a  ce  niveau 
il  n'y  a  plus  pour  lui  que  la  queue  de  cheval. 


Diseases  of  the  Cord. 


69 


bution,  it  is  to  the  muscles  also  of  the  analogous  re- 
gions. 

This  settled  or  accepted,  the  following  (accord- 
ing to  Miiller)  are  the  motor  functions  and  the  sen- 
sory region  of  this  segment  of  the  cord  which  is 
situated  at  the  level  'of  the  second  lumbar  vertebra : 

CoNus  Medullaris. 


C/3    PJ     f6 


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70  The  Diagnosis  of 

From  this  table  the  syndrome  of  the  conus  can 
be  deduced  '}-^  It  is  essentially  made  up  of  troubles 
of  micturition  and  of  defecation  (obstinate  constipa- 
tion or  relaxation  on  the  part  of  the  bowels ;  reten- 
tion or  incontinence  of  urine),  absence  of  erection 
and  anaesthesia  of  the  penis,  urethra,  scrotum,  peri- 
naeum,  anus,  coccyx  and  of  the  sacrum.  This 
picture  is  more  or  less  complete  according  to  the 
case. 

The  morbid  causes  which  can  determine  this 
syndrome  are:. Traumatism  (a  blow  in  this  location, 
a  shot  producing  a  fracture,  a  hemorrhage) ,  tumors 
(Raymond  names  lipomas,  myomas,  sarcomas,  gli- 
omas, cavernous  lymphangiomas,  medullary  can- 
cers), syphilis,  tuberculosis,  meningeal  hemorr- 
hages, etc.     (Duwour). 

As  to  the  differential  diagnosis  that  must  be 
made  from  lesions  of  the  cauda  equina.  This  will  be 
best  considered  after  the  study  of  the  syndrome  of 
the  sacral  cord. 

3.    The    Root- Segmental    Syndrome    of    the 
Sacral  Cord/'^ 

The  sacral  cord  as  to  location  has  nothing  to  do 
with  the  sacrum.  It  corresponds  to  the  first  lumbar 
vertebra  and  gives  rise  to  the  first  sacral  and  the 
last  lumbar  pairs.  Following  is  its  motor  and  sen- 
sory distribution  according  to  Miiller  •}^^^ 

"^Raymond  cite  les  faits  de  Lachmann  (1882),  KirchoflE 
(1884),  et  Oppenheim  (1889),  Lubovitch  (1894,  Revue  neu- 
ral, 1895,  p.  20)  et  Peterson  (1895,  Revue  neural,  1895,  p. 
412)  ont  conteste  qu'une  lesion  limitee  au  seul  cone  ait  pu 
determiner  la  paralysie  complete  de  la  vessie  et  du  rectum. 

^^Voir  les  travaux  deja  cites  pour  le  syndrome  du  cone 
medullaire. 

"°Sano  {Jaurn.  de  neural.  1897,  p.  277)  place  le  centre 
des  muscles  du  pied  et  des  muscles  de  la  jambe  dans  une 


Diseases  of  the  Cord. 
Sacral  Cord. 


71 


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3    3    5"^ 


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n 


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colonne  de  la  4^  sacree  a  le  5^  lombaire ;  le  centre  des  fes- 
siers.  de  la  2^  sacree  a  la  5©  lombaire;  celui  du  quadriceps 
femoral,  de  la  4^  a  la  2©  lombaire ;  celui  des  muscles  abdom- 
inaux,  de  la  i^'^  lombaire  et  au-dessus...Ces  resultats  ont  ete 
discutes  a  la  Soc.  beige  de  neurol. — Van  Gehuchten  et  de 
Buck  {Revue  neurol.  1898,  p.  510)  concluent  de  leurs  re- 
cherches :  "lo  les  noyaux  d'innervation  des  muscles  de  la 
jambe  et  du  pied  occupent  la  partie  posterieure  des  cornes 
anterieures  de  la  moelle  et  s'etendent  depuis  la  partie  super- 


72  The  Diagnosis  of 

To  synthetize  this  table,  placing  man,  as  for  the 
conus  on  four  feet  and  putting  the  lower  limb  in  its 
primitive  position  (turned  outward  at  an  angle  of 
90  degrees  from  the  positive  position)  the  internal 
surface  and  the  large  toe  forward,  we  find  the  sacral 
cord  presides  over  the  sensibility  of  the  posterior 
and  external  surfaces  of  the  lower  limbs  coj^re- 
sponding  to  a  long  posterior  surface  of  this  lower 
limb  (including  the  sole  of  the  feet)  ;  the  muscles 
(rotation  outward,  flexor  of  leg  and  extension  of 
foot)  are  also  those  of  the  posterior  surface.    • 

Following  are  the  various  partial  paralyses,  the 
superposition  of  which  constitutes  the  total  motor 
syndrome  of  the  sacral  cord:  pes  valgus,  (long  pe- 
roneus),  pes  varus  (short  peroneus),  impossibility 
-of  flexing  the  foot  on  adduction  (anterior  tibial 
group),  impossibility  of  flexing  the  foot  on  abduc- 
tion (long  extensor  of  the  toes),  foot  drop,  steppage 
(whole  of  the  external  popliteus),  equilibrium  in 
walking^ ^^  but  not  static  coordination ;  mipossibility^ 
of  extending  the  foot,  of  flexing  and  turning  the 
toes  laterally  (internal  popliteus),  impossibility  of 
flexing  the  leg  on  the  thigh  (semi-tendinous,  semi- 
membranous, biceps)  ;  abduction  of  the  thigh  im- 

ieure  du  5^  segment  lombaire  j usque  vers  Textremite  inferi- 
eure  du  4©  segment  sacre;  20  il  existe  deux  grands  noyaux 
d'innervation  de  ce  segment  du  membre  inf erieur ;  un  pre- 
mier noyau  tres  grand,  comportant  probablement  plusieurs 
subdivisions,  s'etend  de  I'extremite  superieure  du  5©  segment 
lombaire  jusqu'a  la  partie  inferieure  du  3^  segment  sacre; 
und  second  noyau,  egalement  assez  volumineux,  surtout  vers 
son  milieu,  mais  semblant  unique,  commence,  en^  arriere  du 
premier,  a  partir  du  2^  segment  sacre  et  s'etend  j  usque  vers 
I'extremite  inferieure  du  46  segment  sacre." 

"^Voir  mes  leg.  sur  un  cas  de  pseudo-tabes  post-infectieux 
(par.  symetr.  posterysipel.  du  tibial  anter.),  in  Leg.  de  Clin, 
med.   1896;  26  serie,  p.  245. 


Diseases  of  tJie  Cord.  ^         73 

possible,   rotation   difficult,   difficulty     in      climl)ing 
stairs  (glutei). 

For  the  sensibility  the  anaesthesia  includes :  in 
front,  the  upper  part  of  the  foot  and  the  external 
part  of  the  leg ;  behind,  all,  except  the  internal  part 
of  the  leg  and  the  lower  half  of  the  thigh. 

To  make  the  sensory  syndrome  of  the  sacral  cord 
complete  it  is  necessary  to  add  to  this  distribution 
the  anaesthesia  of  the  conus  meduUaris,  the  topo- 
graphy of  which  we  described  above. 

The  pains,  when  they  exist,  will  be  in  the  domain 
of  the  sciatic. 

But,  to  appreciate  the  semeiological  value  of  a 
pain  from  the  point  of  its  location  it  must  be  re- 
•called  that  it  is  there  a  phenomenon  of  excitation  and 
not  of  destruction,  and  that  in  consequence  the  seat 
-of  a  pain  often  indicates  a  point  near  the  diseased 
region  rather  than  the  altered  part  itself. 

To  complete  the  syndrome  it  is  necessary  to 
know  the  reflexes  which  have  their  centers  below  or 
at  the  level  of  the  sacral  cord. 

We  already  know  that  in  the  conus  are  the  ano- 
vesical  and  genital  reflexes.  In  lesions  of  the  sacral 
■cord  these  reflexes  will  often  be  exaggerated  (re- 
tention and  priapism)  at  other  times  diminished  or 
abolished  (incontinence,  impotence). 

In  the  sacral  cord  are  the  plantar  and  tendon 
Achilles  reflexes. 

The  plantar  reflex  is  a  cutaneous  reflex  which 
we  studied  above  apropos  to  its  qualitative  altera- 
tion described  by  Babinski.  In  the  normal  state  it 
responds,  according  to  Babinski,^^^  by  a  general 
flexion  of  the  thigh  on  the  pelvis,  of  the  leg  on  the 
thigh,  and  of  the  toes  on  the  metatarsals.     Bris- 

"^Babinski.    Soc.  de  biol.  22  fevr.  1896.  Cit.  Ganault. 


74  The  Diagnosis  of 

saud^^^  studied  the  slightest  manifestations  of  this 
reflex  and  demonstrated  them  in  the  isolated  con- 
traction of  the  adductors  (adduction  of  the  point  of 
the  foot)  and  especially  in  the  isolated  contraction  of 
the  tensor  of  the  fascia  lata. 

Ganault^^*  confirmed  Brissaud's  conclusions  and 
added  for  other  cases  the  contraction  of  some  special 
foot  muscles. 

The  center  of  this  plantar  reflex  is  in  the  sacral 
cord :  center  of  the  2nd  and  3rd  sacral  roots  when  it 
acts  only  by  movements  limited  to  the  toes,  5th  lum- 
bar segment  when  there  is  contraction  of  the  tensor 
of  the  fascia  lata,  the  whole  of  the  sacral  cord  when 
plantar  excitation  causes  all  the  reflex  flexion  of  the 
lower  limb. 

This  is  the  first  reflex  which  will  be  abolished  in 
destructive  lesions  of  the  sacral  cord. 

The  reflex  of  the  tendon  Achilles  has  its  center 
in  the  first  sacral  segment  (Gowers).^^^  It  also  will 
be  abolished  in  destructive  lesions  of  the  sacral  cord. 

With  the  whole  of  these  considerations  of  the 
nervous  troubles,  the  anaesthesia  and  the  state  of  the 
reflexes  we  have  an  entire  syndrome  of  the  sacral 
cord. 

The  differential  diagnosis  of  this  syndrome  of 
the  sacral  cord  is  to  distinguish  it  from  that  of  the 
Cauda  equina.  It  is  at  times  difficult,  at  least  when 
it  affects  the  lower  portion  of  the  cauda  equina 
which  corresponds  to  the  sacrum ;  for  in  its  upper 
part  it  includes  the  lumbar  and  sacral  roots  together, 
and  the  diagnosis  must  be  made  rather  from  the 

"^Brissaud.  Le  refl.  du  fascia  lata.  Gas.  hebdom.  1896, 
p.  253. 

^"Ganault.  Contr.  a  Tetude  de  quelques  refl.  dans 
rhemipl.  de  cause  organ.  1898,  p.  86. 

"^GowERS.   Cit.  Sternberg. 


Diseases  of  the  Cord.  75 

syndrome  of  the  lumbar  cord.  But  in  its  lower  part 
the  Cauda  equina  includes  only  the  sacral  roots, 
wherefore  its  alteration  will  give  the  same  symptom- 
atology as  the  alteration  of  the  centers  of  these 
roots.  For  the  sacral  nerves  it  is  a  question  (which 
occurs  for  all  nerves')  of  differential  diagnosis  be- 
tween nuclear  and  root  paralyses  (or  neuritic)  ;  for 
the  root  lesions  are  intra-spinal  neuritic  lesions. 

Nothing  proves  better  the  diffirnltv  of  this  diag- 
nosis than  the  case  in  which  Erb^^®  claimed  a  lesion 
of  the  Cauda  equina,  and  at  autopsy  seven  years  later 
Schultze^^^  established  a  lesion  of  the  cord.  Bech- 
terew^^^  also  thinks  "That  it  is  impossible  to  know 
whether  a  lesion  involves  the  cord  or  the  roots  to 
which  the  medullary  segment  gives  rise." 

I  however  believe  this  diagnosis  possible,  at  least 
in  certain  cases. ^^^ 

Nothing  can  be  deduced  from  the  anaesthesias, 
paralyses  or  amyotrophies.  They  are  the  same  for 
the  nerves  whatever  may  be  the  height  of  the  lesion. 
The  reaction  of  degeneration,  the  symmetry  of  the 
affection,  the  cause,  the  onset  and  evolution  of  the 
disease  can  do  nothing  to  make  the  diagnosis  clearer. 

On  the  contrary,  I  believe  the  consideration  of 
„the  following  four  orders  of  symptoms  are  useful: 

I.  The  objective  and  often  external  signs  which 
indicate  the  location  and  height  of  the  lesion :  spon- 

"®Erb..  Ueb.  Spinallahm  (poliomyel.  anter.  acuta)  bei 
Erwachs.  u.  lib.  verw.  spin.  Erkrank.  Arch.  f.  Psych.  1875, 
t.  V,  p.  758.   Obs.  VI. 

"^ScHULTZE.  Z.  different.  Diagn.  d.  Verletz.  d.  Cauda  eq. 
und  d.  Lendenanschw.  D.  Zeitschr.  f.  Nervenh.  1894,  t.  V, 
p.  147. 

^^^Bechterew.  Cit.  DuFOUR^  loc.  cit.,  p.  62. 

^^"Voir  mes  leg.  citees  sur  les  paral.  nucleaires  des  nerfs 
sacres,  p.  269. 


76  The  Diagnosis  of 

taneous  or  provoked  pains/*''  gibbosity,  displace- 
ment. These  signs,  often  very  useful,  are  not  of  ab- 
solute value.  An  intra-spinal  post-traumatic  hemor- 
rhage may  not  show  and  especially  remain  at  the 
very  place  of  the  traumatism.  Dufour  has  indeed  re- 
marked that  the  dura  mater  in  the  cauda  equina  pro- 
tects the  lumbar  roots  more  than  the  sacral  roots. ^^^ 

2.  The  dissociation  of  certain  reflexes  when  it 
exists :  I  speak  of  the  abolition  of  certain  reflexes 
and  the  exaggeration  of  others  below. ^^- 

3.  The   syndrome   of    Brown-Sequard   when   it 
exists    (which   is   very    frequent)    anaesthesia   more  , 
marked  on  one  side,  paralysis  more  marked  on  the 
other,  proving  a  medullary  origin. 

4.  The  dissociation  called  syringo-myelic,  when 
found,  is  a  good  sign  of  medullary  origin  despite 
the  cases  which  we  have  cited  above  and  in  which 
the  said  dissociation  would  have  been  produced  by 
a  neuritis. 

4.    The  Root  Syndrome  of  the  Lumbar  Cord. 

The  lumbar  cord  which  corresponds  to  the  first 
four  lumbar  roots  is  at  the  level  of  the  bodies  of  the 
loth,  nth  and  12th  dorsal  vertebrae.  Following, 
still  according  to  ]\tuller,  are  its  sensory  and  motor 
regions : 

^*°Le3  donleurs  sont  plus  frequentes  dans  les  lesions  de  la 
queue  de  cheval  que  dans  lesions  de  la  moelle  sacree. 

^*^Le  sac  dural  se  termine  au  niveau  de  la  2^  vertebre 
sacree  et  a  partir  de  ce  point  les  racines  sacrees  (portion 
inferieure  de  la  queue  de  cheval)  sont  plus  exposees,  notam- 
ment  aux  hemorragies  extra-durales,  qui  ne  pouvant  pas 
fihrer  a  travers  le  duremere  se  collecteraient  plus  bas  dans 
le  canal  sacre. 

^*^Nous  retrouverons  mieux  ce  signe  a  propos  de  la  moelle 
lombaire. 


Diseases  of  the  Cord. 


77 


Lumbar  Cord. 


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On  placing  man,  as  for  the  sacral  cord,  on  four 
feet  and  the  lower  limbs  in  the  primitive  position, 
we  see  that  the  lumbar  cord  presides  over  the  sensi- 
bility of  the  internal  and  anterior  surfaces,  that  is  to 
say  of  the  anterior  segment  of  the  lower  limb  and 


78  The  Diagnosis  of 

over  the  mobility  of  the  same  regions   (adductors, 
rotators  within,  extensors  of  the  leg). 

To  sum  up  the  distribution  of  these  three  seg- 
ments of  the  cord,  we  see  that  man  being  in  the  po- 
sition given  above,  the  three  segments  of  the  cord 
which  are  the  one  in  front  of  the  other  (the^  conus 
behind,  the  sacral  cord  in  the  middle,  the  lumbar 
cord  in  front )  respectively  innervate  three  segrfients 
placed  also  one  before  the  other :  the  conus  inner- 
vates the  caudal  segments  (or  its  location),  the  sacral 
cord  innervates  the  postero-external  part  of  the 
lower  extremity,  and  the  lumbar  cord  innervates  the 
antero-internal  part  of  the  lower  extremity. 

These  synthetic  views  should  aid  in  fixing  in  the 
memory  this  sensori-motor  distribution  of  the  three 
first  (lower)  segments  of  the  cord. 

In  every  case  from  the  above  table  it  should  be 
easy  to  deduce  the  syndrome  produced  by  an  entire 
section  of  the  lumbar  cord. 

In  a  word,  there  is  complete  paraplegia  with  an- 
aesthesia up  to  the  low^er  part  of  the  abdomen, 
sphincter  troubles  and  often  bedsores  on  the  sacrum, 
amyotrophy  when  present  is  limited  to  the  muscles 
w^hich  the  table  gives  as  directly  innervated  by  the 
lumbar  cord.  The  muscles  depending  upon  the 
sacral  cord  are  paralyzed  because  their  communi- 
cation with  the  brain  is  interrupted,  but  they  escape 
atrophy  because  their  medullary  center  is  not 
changed.  When  there  is  pain  it  is  generally  at  the 
limits  of  the  lesion;  above  under  the  form  of  ileo- 
lumbar  neuralgia,  below  under  the  form  of  crural  or 
sacral  neuralgias. 

As  to  the  reflexes  we  must  always  distinguish 
between  those  whose  center  is  below  the  lesion  and 
those  whose  center  is  at  the  level  of  the  lesion. 

In  the  first  group  we  have  the  sphincter  reflexes. 


Diseases  of  the  Cord.  79 

the  tonus  of  the  muscles  innervated  by  the  sacral 
cord,  the  plantar  reflex  and  the  tendon  Achilles  re- 
flex. When  (which  is  most  frequent)  the  reflexes 
are  exaggerated  there  is  a  spastic  paraplegia  (at 
least  in  the  sacral  region),  that  is  to  say  the  contrac- 
tures produce  pes  equinus ;  there  is  clonus  and  re- 
tention of  urine  and  faeces. 

Of  the  reflexes  having  their  center  in  the  lum- 
bar cord  itself  the  patellar  tendon  is  the  principal 
one.  The  roots  of  the  lumbar  plexus  make  up  the 
arc.^"^^  The  roots,  the  integrity  of  which  seems 
necessary  for  the  maintenance  of  the  patellar  reflex, 
are  in  the  rabbit  (Tschiriev)  the  6th  lumbar,  in  the 
dog  ( Westphal)  5th,  6th,  7th  lumbar,  in  man  (Cow- 
ers) 2nd,  3rd  and  4th  lumbar.  So  that  the  center 
of  this  reflex  is  in  the  lumbar  cord.  Then,  the  abo- 
lition of  the  patellar  tendon  should  make  a  part  of 
the  syndrome  of  the  lumbar  cord. 

As,  in  another  place,  we  have  seen  that  with  a 
lesion  in  this  location  the  reflex  of  the  tendon  x\chil- 
les  may  be  exaggerated,  we  would  have  this  strange 
dissociation  an  example  of  which  we  have  pub- 
lished,^** on  one  part  abolition  of  the  patellar  tendon 
reflex/*^  and  on  the  other  in  the  same  limb  clonus. 

Another  reflex  (a  skin  reflex)  also  has  its  center 

"'Voir  Sternberg.  D.  Sehnenrefl.  u.  ihre  Bedeut  f.  d. 
Pathol,  d.  Nervensyst.   1893,  p.  34. 

^"Leg.  de  clin.  med.  1898,  3^  serie,  p.  252. 

"^On  pourrait  parler  ici  du  reflexe  contralateral  des  ad- 
ducteurs  de  P.  Marie.  Ce  reflexe  (voir  la  Th.  citee  de 
Ganault,  p.  56)  es  provoque  par  la  percussion  du  tendon 
rotulien  et  peut  persister  alors  que  le  reflexe  rotulien  ordin- 
aire est  aboli,  mais  la  condition  pathogenique  intra-medul- 
laire  de  ce  phenomene  n'est  pas  encore  assez  nettment 
etablie  pour  que  nous  nous  y  etendions  ici.  II  en  est  de 
meme  du  reflexe  rotulien  paradoxal,  c'est-a-dire  des  sujets 
chez  lesquels  la  percussion  du  tendon  rotulien  fait  flechir  la 
jambe  au  lieu  de  la  soul  ever. 


8o  The  Diagnosis  of 

in  the  lumbar  cord,  the  cremasteric/*®  The  quick 
elevation  of  the  testicle  is  produced  by  friction  or 
brusque  pressure  on  the  skin  of  the  supero-mternal 
part  of  the  thigh  or  better  at  the  level  of  the  ring  o£ 
the  third  adductor.  In  the  female  there  would  be 
an  analogous  reflex  from  the  groin,  a  contraction  of 
the  most  inferior  fibres  of  the  abdominal  wall.  The 
center  of  this  reflex  is  in  the  lumbar  cord  (ist^^and 
2nd  segments) . 

Then  the  patellar  and  cremasteric  reflexes  will  be 
abolished  in  lesions  of  the  lumbar  cord  and  this 
abolition  is  contrasted  with  the  maintenance  or  even 
exaggeration  of  the  tendon  Achilles  and  plantar 
reflexes. 

The  differential  diagnosis  is  easier  than  for  the 
sacral  cord  for  lesions  of  the  cauda  equina  cannot 
produce  complete  paraplegia  with  sphincter  troubles. 
The  question  will  arise  only  when  the  syndrome  of 
the  lumbar  cord  is  reduced  and  incomplete. 

On  the  same  principle  given  above  for  the 
sacral  cord  we  may  base  the  following:  the  object- 
ive and  external  signs  will  indicate  the  height  of 
the  lesion  in  the  spinal  column,  the  dissociation  of 
the  reflexes  (very  important),  the  Brown-Sequard 
syndrome  (if  it  were  only  indicated)  and  the  so- 
called  syringo-myelic  dissociation  of  sensibilities. 

5.    The  Segmental  Syndrome  of  the  Lnmbo- 

Sacral  Cord. 

All  we  have  said  in  paragraphs  2,  3  and  4  is 
based  on  the  distribution  of  the  spinal  roots.  It  is 
therefore  the  root  semeiology.  These  are  the  root 
syndromes  of  the  lumbosacral  cord.    By  the  side  of 

"■^Voir  Ganault.  Th.  citee,  p,  3. 


Diseases  of  the  Cord.  8i 

these  it  is  necessary  to  look  at  also  the  segmental 
syndromes  of  the  Inmho-sacral  cord. 

The  characteristic  symptom  is  that  it  is  ssg- 
mental:  there  is  often  here  a  complete  or  dissociated 
anaesthesia ;  it  does  not  correspond  then  either  to  a 
nerve  or  root  distribution,  but  to  a  segment  of  a 
limb;  its  upper  limit  is  a  circular  line  perpendicular 
to  the  axis  of  the  limb. 

When  this  segmental  anaesthesia  is  limited  to  the 
foot,  it  may  be  confounded  with  a  nerve  or  root  an- 
aesthesia (sacral  plexus)  ;  when  it  extends  over  all 
the  lower  extremity  it  may  be  confounded  with  an 
anaesthesia  from  all  the  lumbo-sacral  plexus.  But 
when  it  involves,  for  example,  all  the  lower  part  of 
the  limbs  and  is  limited  above  by  a  circular  line  at 
the  lower  third  of  the  thigh,  neither  the  nerve  nor 
root  distribution  can  be  invoked,  the  segmental  dis- 
tribution must  be  admitted. 

Debove  and  Parmentier^*'  have  observed  some 
cases  of  syringo-myelia  in  which  thermo-analgesia 
or  thermo-anaesthesia  were  thus  disposed  as  stock- 
ings. 

Chipault^*'^  has  described  anaesthesia  from 
Pott's  disease  in  the  shape  of  boots,  in  that  of  long 
stockings  (up  to  the  middle  of  the  thigh)  in  that  of 
drawers  (up  to  the  umbilicus),  and  a  hyperaesthesia 
up  to  the  middle  of  the  thigh  in  a  medullary  disturb- 
ance. 

Thus,  although  the  segmentalization  may  be  less 
distinct  and  less  frequent  in  the  lower  limbs  than  in 

^^'Debove,  in  Leg.  du  mardi  de  Charcot,  t.  II,  p.  506. — 
Parmentier.  Nouv.  Iconogr.  de  la  Salpetr.  1890,  p.  219. 
Cit.  de  Brissaud^  in  Leg.  citees  sur  les  mal,  nerv.,  p.  220. 

^**Chipault.  La  topogr.  de  I'anesth,  pottique.  Revue  neu- 
rol.  1896,  p.  293,  et  Quelques  types  clin.  nouv.  de  les,  radicul. 
et  medull.    Presse  med.  1896,  p.  85. 
6 


82  The  Diagnosis  of 

the  upper,  the  cHnician  must  admit  it.  The  seg- 
mental syndromes  are  recognized  by  their  segmental 
distribution :  the  seat  of  the  lesion  is  in  these  cases 
in  a  section  of  the  lumbo-sacral  cord  as  much  higher 
as  the  segment  of  the  limb  attacked  is  itself  higher. 

6.    The  Root  Syndrome  of  the  Dorsal  Cord. 

The  dorsal  cord,  which  extends  from  the  2nS  to 
the  9th  dorsal  vertebrae,  corresponds  to  the  origin 
of  the  dorsal  pairs  of  nerves  from  the  2nd  to  the 
I2th. 

Each  of  these  nerves  innervates,  from  a  sensory 
point  of  view,  a  band  of  the  trunk.  The  upper  band 
(2nd  dorsal)  extends  from  the  upper  part  of  the  in- 
ternal surface  of  the  arms.  From  the  3rd  to  the  4th 
dorsal  nerves  the  zones  are  above  the  breast,  which 
is  included  in  the  zone  of  the  5th ;  from  this  to  the 
navel  is  included  in  the  zone  of  the  loth.^*^  The 
zone  of  the  12th  is  confined  to  the  upper  zone  of  the 
lumbar  cord.^^^ 

These  zones,  horizontal  to  the  upper  part  of  the 
trunk,  become  more  and  more  oblique  from  above 
downward  and  from  behind  forward  in  proportion 
as  you  descend. 

Each  zone  is  innervated  principally  by  the  cor- 
responding pair  of  nerves  and  accessorily  by  the 
pairs  immediately  above  and  below  (Sherrington). 
It  results,  that  when  a  root  is  cut,  the  anaesthesia  is 
not  complete  in  the  corresponding  region  and  that 
in  a  given  anaesthesia  it  is  necessary  to  look  for  the 

^■*^Un  fait  de  Mackintosh  {The  Brit.  med.  Journ.  1898, 
p.  478.  Revue  neurol.  1898,  p.  203)  montre  que  la  zone  sen- 
sitive de  la  dixieme  racine  dorsale  n'atteint  pas  rombilic. 

^^''Voir  la  distribution  d'apres  ihorburn  in  Marinesco, 
Sent.  mid.  1896.  p.  259.  (iravaux  de  Sherrington.  Hors- 
ley....). 


Diseases  of  the  Cord. 


83 


lesion  four  inches  above  the  line  of       anaesthesia 
(Horsley). 

For    the    motor    distribution    see    the    following 


table  according  to  Testut: 

Intercostal  and 
ext-intercostal. 


Mtiscles. 


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From  the  anatomo-physiological  facts  the  syn- 
drome of  the  dorsal  cord  may  be  easily  deduced: 
Paralysis  and  anaesthesia,  in  a  complete  lesion  of  the 


84  The  Diagnosis  of 

cord,  in  the  whole  region,  motor  and  sensory,  lo- 
cated below  the  lesion.  Beside  the  bedsores,  which 
are  as  in  the  lumbo-sacral  cord,  there  are  other  im- 
portant trophic  disturbances :  there  may  be  a  herpes 
of  the  trunk,  which  then  outlines  the  distribution  of 
the  roots. 

For  the  reflexes  we  will  have  loss  and  more  often 
exaggeration  of  all  those  having  centers  below  the 
dorsal  cord  (the  patellar  tendon  and  cremasteric  are 
included).  As  to  the  reflexes  having  their  center  in 
the  dorsal  cord  and  which  will  be  lost  in  the  total 
destruction  of  the  latter,  the  clinician  recognizes 
only  the  abdominal. ^°^ 

The  abdominal  wall  retracts  if  the  skin  of  the 
belly  is  lightly  stroked  (cutaneous  reflex),  or  when 
this  wall  is  percussed  [tendon  (  ?)  reflex].  As 
studied  by  Rosenbach,  Bodon,  Parisot,  OstankofT, 
Dinkier,  Pitres,  etc.,  this  reflex  pertains  to  the  re- 
gion of  the  9th  (upper  reflex),  loth,  nth,  and  T2th 
(middle  and  lower  reflexes)  pairs  of  intercostal 
nerves. 

We  will  make  the  diiferential  diagnosis  after  the 
following  paragraph : 

7.    The  Segmental  Syndrome  of  the  Dorsal 
Cord. 

The  study  of  medullary  segmentalization  has 
been  made  mostly  from  the  clinical  history  of  zonas 
of  the  trunk  (Brissaud).^^- 

Many  authors^°^  have  already  remarked  clinic- 
ally that  thoracic  zona  is  horizontal  and  often 
xrosses  the  intercostal  paths  instead  of  being  super- 

^^^Ganault.  Th.  citee.   1898,  p.  102. 

"'Brissaud.  Le  zona  du  tronc  et  sa  topogr.  Bull,  med, 
1896,  p.  27  et  87. 

"^Brissaud  cite:  Baerexsprung,  Balmaxno  Squire, 
Leroux,  He.\d. 


Diseases  of  the  Cord.  85 

imposed  upon  them.  Some  have  concluded  from 
this  that  zona  is  not  of  nervous  origin,  others  that 
the  thoracic  nerves  have  one  course,  "sensibly  hor- 
izontal." Both  opinions  are  impossible  to  support. 
Brissaud  was  the  first  to  analyze  and  give  a  theory 
of  the  fact. 

There  are  thoracic  zonas  of  two  nervous  orig- 
ins :  Those  of  neuritic  or  ganglionic  origin  follow 
the  course  of  the  nerves,  the  others  of  medullary 
origin  are  horizontal.  At  the  upper  part  of  the 
thorax  they  are  over  the  nerves,  which  are  also 
horizontal.  But  in  proportion  as  they  descend  the 
nerves  become  more  and  more  oblique  from  above 
downward  and  from  behind  forward,  and  the  zonas 
remain  horizontal,  crossing  the  nerves  at  more  and 
more  of  an  angle. 

These  horizontal  zonas  of  the  trunk  represent 
very  well  the  form  of  the  zones  of  the  distribution 
of  the  various  segments  of  the  dorsal  cord.  The 
neuralgias  and  the  bands  of  anaesthesia,  of  hypaes- 
thesia  or  hypersesthesia,  which  present  the  same 
distribution,  must  be  added  here.  Thus  Achard^-^"^ 
has  described  a  band  of  dissociated  anaesthesia,  the 
topography  of  which  was  exactly  that  of  an  abdom- 
inal zona. 

With  these  various  symptoms  the  complete  seg- 
mental syndrome  of  each  segment  of  the  dorsal 
cord  is  established. 

8.    The  Root  Syndrome  of  the  Brachial  Cord. 

The  brachial  cord,  which  extends  from  the  4th 
cervical  to  the  2nd  dorsal  vertebra,  corresponds 
to  the  origins  of  the  5th,  6th,  7th  and  8th  pairs  of 
cervical  and  of  the  ist  pair  of  dorsal  nerves. 

Following  is  the  table  of  the  sensori-motor  dis- 

^•'*AcHARD.  Syringom.  avec  amyotr.  du  type  Aran-Du- 
chenne  et  anesth.  dissociee  en  bande  zostero'ide  sur  le  tronc. 
Ga;3.  hebdom.  1896,  p.  361  et  Revue  netirol.  1896,  p.  2>77' 


86 


The  Diagnosis  of 


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Brachial  Cord. 


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neurol.   1894,  p.  570 


Starr.   Brain   1894.   p.   481,   Revue 


Pour  simplifier,  je  supprime,  dans  le  tableau  de  Testut, 
les  muscles  a  cote  desquels  il  y  a  un  point  d' interrogation. 


Diseases  of  the  Cord.  87 


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8S  Tlie  Diagnosis  oj 

The  sensory  rcot  distribution  of  the  various  por- 
tions of  the  brachial  cord  may  be  easily  derived  by 
placing  the  subject  on  all  fours,  the  upper  extrem- 
ity turned  at  an  angle  of  90  (in  the  primitive  posi- 
tion), the  thumb  in  advance.  The  sensibility  is  then 
seen  to  be  distributed  in  three  parallel  bands  (each 
occupying  the  entire  length  of  the  extremity),  the 
posterior  innervated  by  the  ist  dcrsal  and  8th  ter- 
vical,  the  middle  by  the  7th,  and  a  part  of  the  6th 
cervical,  the  anterior  by  a  part  of  the  6th  and  the 
5th  cervical. 

Then,  as  for  the  lower  extremity  and  the  trunk,- 
the  zones  of  root  distribution  succeed  each  other 
in  the  same  order  and  manner  as  the  spinal  pairs 
themselves. 

For  the  motor  distribution,  it  may  be  recalled 
that  the  lower  pair  (ist  dorsal)  correspond  to  the 
median  and  ulnar,  the  upper  pairs  (5th,  6th  and  7th 
cervical)  to  the  circumflex  and  radial.  Marinesco 
has  defined  the  position  of  these  nuclei  of  origin  in 
a  recent  work.^^"  He  shows  notably  that  each  nerve 
has  a  principal  nucleus  and  some  accessory  nuclei, 
and  that  each  nerve  derives  its  origin  from  many 
medullary  segments.  "Thus  the  ulnar  and  median, 
the  principal  source  of  which  is  constituted  by  the 
eight  cervical  segment,  still  receive  fibres  from  the 
7th  cervical  and  more  from  the  ist  dorsal." 

The  reHexes  which  have  their  centers  in  this  por- 
tion of  the  cord  are  the  cutaneous  and  tendon  re- 
flexes of  the  upper  extremity,  the  tendon  reflex  of 
the  biceps  having  the  highest  medullary  center  { 5th 
cervical). 

In  the  same  region  is  also  the  cilio-spinal  center, 

^^']\Iarinesco.  Contr.  a  I'etude  des  localisat.  des  noyaux 
moteurs,  dans  la  nioelle  epin.  Rcvuc  nciivol.   1898.  p.  463. 


Diseases  of  the  Cord.  89 

the  presence  of  which  is  important  in  the  semeiology 
of  this  region.  The  exciting  oculo-pupillary  fibres 
leave  the  cord  by  the  8th  cervical  and  especially  the 
1st  dorsal,  and  reach  by  the  rami  communicantes  the 
inferior  cervical  sympathetic  ganglion. 

The  experiments  of  Claude  Bernard  and  Mad- 
ame Dejerine-Klumpke  (1885)  show  that  when 
in  an  animal  a  section  or  laceration  of  the  roots  of 
the  brachial  plexus  is  made,  pupillary  phenomena 
are  seen  to  follow  whenever  the  rami  communi- 
cantes of  the  first  dorsal  pair  are  injured,  and  only 
then. 

There  are  also  some  confirmatory  clinical  facts. 
Raymond^^^  cites  those  of  Prevost,  Pfeififer,  Heub- 
ner,  Bruns,  Monter,  Muller,  and  particularly  Sands 
and  Seguin  (1873).  In  the  last  case  there  was 
traumatic  paralysis  of  the  brachial  plexus  without 
oculo-pupillary  symptoms.  To  stop  the  violent  pains 
Seguin  cut  the  lower  roots  of  the  plexus,  and  my- 
osis  appeared.  Oppenheim  was  able  to  excite  the 
first  dorsal  pairs  in  a  man  whose  spine  he  had  tre- 
phined. Excitation  of  the  first  dorsal  pair  alone 
determined  a  considerable  mydriasis,  which  was 
maintained  for  some  seconds. 

Clinically,  if  the  mydriasis  indicates  excitation 
of  this   cilio-spinal   center    (the   lower  part   of  the 

'"^Raymond.  Paral.  radicul.  du  plexus  brach.  (7  dec. 
1894)  ;  paral.  radicul.  sensit.  du  plex.  brach.  (22  mars  1805)  : 
un  cas  de  paral.  radicul.  du  plex.  brach.  dr.  (24  avril  1896). 
Leq.  sur  les  mal.  du  syst.  new.  1806  t.  I,  p  217  et  ^^o- 
1897,  t.  II,  p.  379.  ^  '         '   "^  ^'^' 


9©  The  Diagnosis  of 

brachial  cord),  a  destructive  lesion  of  this  same  re- 
gion of  the  cord  would  bring  about  myosis,  narrow- 
ing of  the  palpebral  fissure  and  retraction  of  the 
ocular  globe. 

From  all  this  the  description  of  the  root  syn- 
drome of  the  brachial  cord  easily  results :  5^ins, 
paralysis,  ^nsesthesias,  amyotrophies,  vaso  motor 
troubles  and  reflexes  are  distributed  according  to  the 
anatomo-physiological  table  which  we  give. 

The  syndrome  may  moreover  be  total  or  partial. 
In  the  latter  group  there  are  many  varieties,  but  two 
principal  types  may  be  easily  distinguished :  the  su- 
perior and  inferior  types. 

In  the  superior  type  (Erb,  Duchenne),  the  del- 
toids, biceps,  brachialis  anticus  and  supinator 
longus  (Erb)  are  involved,  and  often  also  the  supra 
and  sub-spinous  muscles,  the  clavicular  bundle  of 
the  pectoralis  major,  the  supinator  brevis  (Du- 
chenne). It  is  a  paralysis,  partial  or  complete,  of 
the  5th  and  6th  cervical  pairs. 

In  the  inferior  type  (Klumpke)  the  muscles  of 
the  median  and  ulnar  are  attacked :  paralysis  of  the 
1st  dorsal  pair. 

The  oculo-pupillary  troubles  serve  only  to  estab- 
lish the  height  of  the  lesion.  They  also  permit  one 
to  say  whether  the  lesion  is,  in  certain  cases,  in  the 
brachial  plexus  or  in  its  roots.  For  the  troubles  do 
not  appear  when  the  same  nerves  (8th  cervical  and 
1st  dorsal)  are  affected  below  the  emergence  of  the 
rami  by  the  great  sympathetic.  This  is  then  a  potent 
element  in  differential  diagnosis. 


Diseases  of  the  Cord.  91 

9.     The  Segmental  Syndrome  of  the  Brachial 
Cord. 

Brissaud  derived  the  theory  of  medullary  seg- 
mentation from  the  segmental  anaesthesias  of  the 
limbs  in  syringo-myelia  and  from  the  segmental 
zonas  of  the  limbs. 

For  the  syringo-myelia^^^  he  cites  a  case  of  Gil- 
les  de  la  Tourette  and  Zaguelmann  (1889),  and  one 
of  Parmentier  (1890)  of  thermo-anaesthesia  as 
gloves  (long  ones  up  to  the  elbow),  then  a  case  of 
Debove  and  one  of  Souques  (1891)  of  dissociated 
anaesthesia  as  sleeves.  He  analyses  the  cases  and 
shows  that  especially  for  the  gloves,  a  part  of  three 
nerves,  ulnar,  median  and  radial,  are  necessary. 

It  is  not  the  root  distribution  which  we  know 
to  be  in  longitudinal  bands  parallel  to  the  axis  of  the 
limb.  It  is  the  segmental  distribution  correspond- 
ing to  the  medullary  segmentation. 

For  the  sonas'^^^  it  is  also  seen  that  the  eruption 
presents  a  segmental  distribution.  Such  are  the 
cases  of  Head  and  Mankopf. 

Brissaud  next  notices  that  it  is  the  same  in  many 
cutaneous  diseases.  "Thus  the  case  of  sebaceous 
ichthyosis  of  Biefel  has  the  transverse  zones  of  syr- 
ingo-myelia. On  the  arms  in  particular,  two  large 
cylindrical  bracelets  surround  the  middle  portion  of 
the  humeral  region."  In  a  recent  work  on  the  rela- 
tion of  chronic  eczema  to  anaesthesia  of  the  skin, 
Stonkovenkoff  and  Nikolski  have  noted  the  exist- 
ence of  anaesthesias  in  symmetrical  patches  and  per- 

^''''Brissaud.  Leg.  sur  les  mal.  nerv.  1895,  p.  215. 

""Brissaud.  Sur  la  distribut.  metamer.  du  zona  des 
membr.  Presse  med.  11  Janvier  1896  et  Revue  neurol  1896, 
p.  710. 


92  The  Diagnosis  oj 

pendicular  to  the  axis  of  the  Hmbs  in  subjects  hys- 
terical or  not  hysterical. 

Finally,  scleroderma^^^  which  may  be  distrib- 
uted according  to  the  track  of  a  nerve  or  present  a 
root  topography,  may  also  have  a  segmental  distrib- 
ution. 

For  the  motor  nerves,  Joseph  CoUins^^^  has  al- 
ready established  that  ''the  cell  groups  which  give 
origin  to  the  brachial  plexus  are  three  in  number, 
and  extend  from  the  upper  part  of  the  4th  cervical 
pair  to  the  lower  part  of  the  ist  dorsal.  The  cells 
of  the  upper  part  of  this  area  supply  the  muscles  of 
the  shoulder  and  arm.  The  cells  of  the  lower  part 
supply  the  forearm  and  hand. 

The  nuclei  of  the  flexors  are  external  and  at  a 
lower  level  than  those  of  the  extensors.  The  cells 
which  give  rise  to  the  nerves  which  innervate  the 
extensors  are  situated  nearer  the  median  line  than 
those  which  innervate  the  flexors. ^^^ 

The  same  year  from  a  case  of  muscular  atrophy 
with  autopsy,  Graham  M.  Hammond^^*  concludes 
also  that  one  cellular  group  of  the  cord  gives  rise 
to  the  muscular  nerves  of  the  forearm  and  another 
,group  to  those  of  the  hand. 

More  recently,  I  myself^^°  described  a  segmental 

^®^Brissaud.  Pathogenic  du  processus  scleroderm.  Presse 
med.  1897,  p.  285  {Revue  neuroL  1897,  p.  365)  et  Drouin. 
Quelques  cas  de  sclerod.  local,  a  distrib.  metamer.  Th.  Paris 
1898. 

^'''Joseph  Collins.  The  New-York  med.  Journ.  1894, 
p.  40  et  98.    Revue  neurol.  1894,  p.  105. 

^'^On  peut  rapprocher  ces  donnees  de  celles  que  Marin- 
esco  a  invoquees  pour  expliquer  la  frequence  de  la  "main  de 
predicateur"  dans  la  syringomyelic. 

"*Groeme  M.  Hammond.  The  New-York  med.  Journ. 
1894,  p.  I.  Revue  neurol.  1894,  p.  116. 

'^^Congres  des  neurolog.  de  Marseille,  avril  1899.  Voir 
.aussi.  nos  leg.  sur  Ics  Sympt.  scgmentaires  de  la  moclle  que 
Je  Dr  Gibcrt  va  publier  dans  le  Nouveau  Montpellier  med- 


Diseases  of  the  Cord.  93, 

tremor   (hand  and  wrist)   in  a  case  of  sclerosis  in 
patches. 

The  segmental  syndrome  of  the  brachial  cord 
is  then  thus  characterized  by  sensory,  trophic  or  mo- 
tor symptoms  having  for  their  common  character 
the  involvement  of  a  segment  of  the  limb  limited  by 
a  circular  line  perpendicular  to  the  axis  of  the  limb- 
(line  of  amputation  or  of  disarticulation). 

10.    The  Syndrome  of  the  Cervical  Cord. 

We  include  under  the  name  cervical  cord  only 
the  portion  of  the  cord  which  corresponds  to  the 
first  3  vertical  vertebrae  and  gives  rise  to  the  first 
4  cervical  pairs. 

From  tne  sensory  point  of  view  this  medullary 
segment  innervates  the  neck  and  the  occipital  re- 
gion, above  the  region  (already  described)  of  the 
brachial  and  dorsal  cords  and  hmited  by  the  region, 
of  the  trigeminal.  Its  line  of  demarcation  from  the 
latter  region^*^*^  follows  the  inferior  border  of  the 
lower  jaw  and  the  posterior  border  of  its  upright 
branch,  passes  in  front  of  the  ear  and  goes  straight 
up  to  the  top  of  the  head  to  join  the  same  line  of/ 
the  opposite  side.  In  this  sensory  region  of  the 
cervical  plexus  the  posterior  nart  is  innervaied  by 
the  posterior  branches  (sub-occiptales)  of  the  first 
2  cervical  nerves,  and  the  anterior  part  by  the  an- 
terior branches  of  the  first  4  cervical  nerves. 

Here  is  the  table    (after  Testut)   of  the  motor 
distribution  of  the  first  4  cervical  pairs  •}*'' 

ical  et  le  fait  d'amyotrophie  en  gant  que  vient  de  pubUer  le 
Dr  Crocq  {J own.  de  ncuroL). 

"'''Voir  la  fig.  485  de  la  p.  576  du  t.  II  du  Traite  d'anat  d. 
Testut,  36  edit.  1897. 

""Mayet.  Traite  de  diagn.  med.  et  de  semeiol.  1898,  t  I 
536.  >  ■    " 


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Diseases  of  the  Co?'d.  95 

In  resume,  for  the  sensibility,  on  putting  the 
subject  on  four  feet,  the  head  hanging  (the  neck 
and  occiput  in  front),  the  cervical  plexus  gives  two 
bands,  one  anterior  (the  occipital  region  and  the 
neckj,  the  other  posterior  (the  ear  and  anterior 
part  of  the  neck). 

The  topography  of  the  anaesthesias  in  lesions  of 
this  cord  are  naturally  deduced  from  that.  The 
pains  are:  ist,  painful  torticollis,  pains  at  the  neck 
and  at  the  occiput  as  a  collar ;  2nd,  the  length  of 
the  phrenic  (from  the  base  of  the  chest  or  in  the 
shoulder  with  painful  points  at  the  level  of  the  costal 
insertions  of  the  diaphragm — 7th  to  loth  rib — to 
the  neck  in  front  of  the  anterior  scalenus,  behind  to 
the  limit  of  the  spinous  processes  of  the  3rd  and  4th 
cervical). 

For  motility,  the  cervical  cord  presides :  ist. 
over  the  various  movements  of  the  head  on  the 
trunk  (flexion,  rotation,  extension)  ;  2nd,  over  the 
movements  of  the  diaphragm  (phrenic).  The  symp- 
toms of  excitation  or  of  paralysis  of  the  first  mus- 
cular group  are  easily  foreseen:  Convulsions  (tics) 
or  paralysis  of  rotation,  of  flexion  or  of  extension 
-of  the  head.  As  to  the  diaphragm,  Duchenne  lias 
established  the  symptoms  of  its  paralysis. 

In  inspiration  the  epigastrium  and  hypochondriac 
regions  are  depressed  instead  of  dilated,  at  the 
same  time  that  the  thorax  increases  in  volume,  and 
inversely  during  expiration.  If  there  is  simply  a 
paresis,  the  phenomenon  appears  only  in  deep  or 
agitated  respirations ;  if  the  paralysis  is  unilateral,  it 
appears  only  on  one  side.  At  the  same  time  respira- 
tion is  more  frequent,  especially  on  the  least  effort 
to  walk  or  speak  or  on  the  least  excitement.  All  the 
extraordinar}^  muscles  of  inspiration  become  active 
then,  the  face  is  flushed  and  the  patient  sufifocates. 


96  The  Diagnosis. 

The  voice  is  feeble  and  the  slightest  utterance  puts 
him  out  of  breath.  Expectoration  is  difficult  or  im- 
possible. Defecation  requires  great  efforts  and  is 
accomplished  with  much  difficulty. 

The  differential  diagnosis  of  this  cervical  syn- 
drome should  be  made  from  the  brachial  or  dorsal 
S}'ndrome  and  from  the  bulbar  syndrome. 

The  first  will  be  made  by  the  presence  of  symp- 
toms which  from  the  beginning  pertain  exclusively 
to  the  cervical  cord  and  which  we  have  described. 

The  second  will  be  made  by  the  absence  of  truly 
bulbar  symptoms  such  as  ocular  paralyses,  paralyses 
of  the  lips,  tongue,  deglutition,  anaesthe:sias  of  the 
trigeminal,  etc. 


TABLE  OF   CONTENTS. 


Introduction,  ....  3 

I.     The  Diagnosis  of  Disease  of  the  Medul- 
lary System,  •  .  .  .  5 

1.  The  syndrome  of  the  posterior  columns: 

sensory  and  ataxic  disturbances,     .  6 

2.  The  syndrome  of  the  antero-lateral  col- 

umns :  pareto-spasmodic  state,  con- 
tractures and  intention  tremor,       .  17 

3.  The  associated  syndrome   of  the  poste- 

rior and  lateral  columns:  ataxo-spas- 
modic  state,    ....  30 

4.  The    syndrome    of  the    anterior    horns: 

muscular  atrophy,      .  .  .  31 

5:  The  associated  syndrome  of  the  lateral 
columns  and  the  anterior  horns:  spas- 
tic muscular  atrophy,  .  -35 

6.  The    syndrome    of  the    centrp  posterior 

grey  substance;  syringo-myelic  disso- 
ciation of  sensibility  (and  vaso-motor 
troubles),         .  .  .  .  ;^6 

7.  The  associated  syndrome  of  the  anterior 

horn  and  of  the  centro-posterior  grey 
substance  (syndrome  of  the  whole  grey 
substance):  muscular  atrophy,  syringo- 
myelic dissociation  of  sensibility  and 
vaso-motor  troubles,  .  .  52 

8.  The  syndrome  of  the  lateral  half  of  the 

cord:   crossed  hemiparaplegia,         .  53 


ii  Table  of  Contents. 

II.     The   Diagnosis   of   the    Height  of  the 

Medullary  Lesion,  .  .  62 

1.  General    principles    of  the  diagnosis  of 

the  height  of  lesions,  .  .  62 

2.  The    root-segmental    syndrome    of    the 

conus  medullaris,       .  ,  .      *     68 

3.  The    root-segmental    syndrome    of    the 

sacral  cord,    ....  70 

4.  The     root-segmental    syndrome    of    the 

lumbar  cord,  .  .  .  76 

5.  The   segmental   syndrome  of  the  lumbo- 

sacral cord,    .  .  .  .  80 

6.  The  root  syndrome  of  the  dorsal  cord,     82 

7.  The  segmental   syndrome   of  the  dorsal 

cord,    .....  84 

8.  The  root  syndrome  of  the  brachial  cord,      85 

9.  The  segmental  syndrome  of  the  brachial 

cord,     ,  .  .  .  .91 

10.     The  syndrome  of  the  cervical  cord,  93 


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